Provider Demographics
NPI:1619019197
Name:STEPHEN R. KELLER, O.D., INC.
Entity Type:Organization
Organization Name:STEPHEN R. KELLER, O.D., INC.
Other - Org Name:ALTA LOMA OPTOMETRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-989-1791
Mailing Address - Street 1:9596 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-5034
Mailing Address - Country:US
Mailing Address - Phone:909-989-1791
Mailing Address - Fax:909-989-0782
Practice Address - Street 1:9596 BASELINE RD
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91701-5034
Practice Address - Country:US
Practice Address - Phone:909-989-1791
Practice Address - Fax:909-989-0782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT10085T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD003130Medicaid
CA1148690001Medicare NSC
CAZZZ18316ZMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER