Provider Demographics
NPI:1265718316
Name:KELLER, THOMAS VERNON (DC)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:VERNON
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 1:2101 SOUTH 10TH STREET
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-5006
Mailing Address - Country:US
Mailing Address - Phone:209-826-9553
Mailing Address - Fax:209-826-9553
Practice Address - Street 1:2101 SOUTH 10TH STREET
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-5006
Practice Address - Country:US
Practice Address - Phone:209-826-9553
Practice Address - Fax:209-826-9553
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10731111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0107310Medicare PIN