Basic Information
| Provider Information | |||||||||
| NPI: | 1720052640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLER | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSED, BSN, RN, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2232 S MICHELLE ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672076690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138508388 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5500 E KELLOGG DR | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672181607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166852221 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 01/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 24-00315 | KS | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 163WP2201X | 13-116483-012 | KS | Y | Nursing Service Providers | Registered Nurse | Ambulatory Care |
ID Information
| ID | Type | State | Issuer | Description | 24-00315 | 01 | KS | KANSAS STATE BOARD OF HEALING ARTS (ATHLETIC TRAINER) AT | OTHER | 13-116483-012 | 01 | KS | KANSAS STATE BOARD OF NURSING (REGISTERED NURSE) | OTHER |