Provider Demographics
NPI:1326337783
Name:KELLER ORTHOTICS INC
Entity Type:Organization
Organization Name:KELLER ORTHOTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-929-4700
Mailing Address - Street 1:2451 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1509
Mailing Address - Country:US
Mailing Address - Phone:773-929-4700
Mailing Address - Fax:
Practice Address - Street 1:1611 W HARRISON ST
Practice Address - Street 2:STE 109
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:312-226-6722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KELLER ORTHOTICS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-06
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL0290650003Medicare NSC