Provider Demographics
NPI:1407664212
Name:KELLER, CARL F III
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:F
Last Name:KELLER
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15775 OAK CHASE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-9721
Mailing Address - Country:US
Mailing Address - Phone:479-841-8132
Mailing Address - Fax:
Practice Address - Street 1:303 W CENTER ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-5102
Practice Address - Country:US
Practice Address - Phone:479-973-4801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR26249146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate