Provider Demographics
NPI:1912529934
Name:KELLER, CALVIN WOODROW (LAT-ATC)
Entity type:Individual
Prefix:MR
First Name:CALVIN
Middle Name:WOODROW
Last Name:KELLER
Suffix:
Gender:M
Credentials:LAT-ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 LODGE DR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360-2802
Mailing Address - Country:US
Mailing Address - Phone:336-906-2202
Mailing Address - Fax:
Practice Address - Street 1:3507 MIDWAY SCHOOL RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-8741
Practice Address - Country:US
Practice Address - Phone:336-474-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-08102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer