Provider Demographics
NPI:1649393943
Name:LESLIE KEELER
Entity Type:Organization
Organization Name:LESLIE KEELER
Other - Org Name:CELINESFARM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KEELER
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:307-472-1919
Mailing Address - Street 1:630 10 MILE ROAD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604
Mailing Address - Country:US
Mailing Address - Phone:307-262-8084
Mailing Address - Fax:307-472-1919
Practice Address - Street 1:630 10 MILE ROAD
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604
Practice Address - Country:US
Practice Address - Phone:307-262-8084
Practice Address - Fax:307-472-1919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119001600Medicaid