Provider Demographics
NPI:1508893785
Name:KELLER, SCOTT (DC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE #8
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7647
Mailing Address - Country:US
Mailing Address - Phone:631-738-8300
Mailing Address - Fax:631-738-8500
Practice Address - Street 1:2805 VETERANS MEMORIAL HWY
Practice Address - Street 2:SUITE #8
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7647
Practice Address - Country:US
Practice Address - Phone:631-738-8300
Practice Address - Fax:631-738-8500
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007598111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU57354Medicare UPIN
NYX08831Medicare ID - Type Unspecified