Provider Demographics
NPI:1518471861
Name:KELLER, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 SPRING LKS
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-3963
Mailing Address - Country:US
Mailing Address - Phone:198-521-7058
Mailing Address - Fax:
Practice Address - Street 1:2815 SPRING LKS
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-3963
Practice Address - Country:US
Practice Address - Phone:985-217-0584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-23
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA153916163WC0400X, 163WC1500X, 163WD1100X, 163WH1000X, 163WH0200X
246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Multi-Specialty
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WD1100XNursing Service ProvidersRegistered NurseDialysis, Peritoneal
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy