Provider Demographics
NPI:1588230429
Name:KELLER, LUCAS
Entity type:Individual
Prefix:
First Name:LUCAS
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 1:17850 28TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:ND
Mailing Address - Zip Code:58521-9773
Mailing Address - Country:US
Mailing Address - Phone:701-471-6016
Mailing Address - Fax:
Practice Address - Street 1:3080 E GENTRY WAY STE 180
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3014
Practice Address - Country:US
Practice Address - Phone:208-939-3334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-73682251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics