Provider Demographics
NPI:1306889548
Name:KELLER, JARROD RALPH (OD)
Entity type:Individual
Prefix:DR
First Name:JARROD
Middle Name:RALPH
Last Name:KELLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1066 BOILING SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-2247
Mailing Address - Country:US
Mailing Address - Phone:864-582-0286
Mailing Address - Fax:864-582-0279
Practice Address - Street 1:1066 BOILING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-2247
Practice Address - Country:US
Practice Address - Phone:864-582-0286
Practice Address - Fax:864-582-0279
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC1359152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD13590Medicaid
SC5917600001Medicare NSC
SCD13590Medicaid
SCAA11318358Medicare ID - Type UnspecifiedMEDICARE