Provider Demographics
NPI:1659723989
Name:KELLER, JUSTIN D (DC)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:D
Last Name:KELLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18919 DOUBLE T LN
Mailing Address - Street 2:
Mailing Address - City:LENORE
Mailing Address - State:ID
Mailing Address - Zip Code:83541-6088
Mailing Address - Country:US
Mailing Address - Phone:208-816-3365
Mailing Address - Fax:208-799-3375
Practice Address - Street 1:3510 12TH ST
Practice Address - Street 2:200
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5575
Practice Address - Country:US
Practice Address - Phone:208-799-3333
Practice Address - Fax:208-799-3375
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIN-1718111NS0005X
IDCHIA-1739111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician