Provider Demographics
NPI:1578889234
Name:LISA S KELLER OD INC
Entity Type:Organization
Organization Name:LISA S KELLER OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:314-497-3042
Mailing Address - Street 1:508 PATTON DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-3103
Mailing Address - Country:US
Mailing Address - Phone:314-497-3042
Mailing Address - Fax:
Practice Address - Street 1:1205 W FERDON ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-4454
Practice Address - Country:US
Practice Address - Phone:217-324-5004
Practice Address - Fax:217-324-5438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010168305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service