Provider Demographics
NPI:1790873214
Name:KEHLER, KEITH GORDON
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:GORDON
Last Name:KEHLER
Suffix:
Gender:M
Credentials:
Other - Prefix:MRS
Other - First Name:KEITH
Other - Middle Name:GORDON
Other - Last Name:KEHLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:910 POINT VIEW LN
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2823
Mailing Address - Country:US
Mailing Address - Phone:863-790-7797
Mailing Address - Fax:
Practice Address - Street 1:6935 S. CARTER ROAD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813
Practice Address - Country:US
Practice Address - Phone:863-648-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS15675183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist