Provider Demographics
NPI:1215925482
Name:KEELEY, MARK JAMES (RD,LD,CDE)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:JAMES
Last Name:KEELEY
Suffix:
Gender:M
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 W DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3612
Mailing Address - Country:US
Mailing Address - Phone:918-456-9334
Mailing Address - Fax:
Practice Address - Street 1:900 N OWEN WALTERS BLVD
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:OK
Practice Address - Zip Code:74365-5003
Practice Address - Country:US
Practice Address - Phone:918-434-8500
Practice Address - Fax:918-434-5051
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD333133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered