Provider Demographics
NPI:1962998161
Name:KELLERLIFE, LLC
Entity type:Organization
Organization Name:KELLERLIFE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL INFORMATICIST
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-294-1386
Mailing Address - Street 1:111 S HEARTHSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-5010
Mailing Address - Country:US
Mailing Address - Phone:480-656-1070
Mailing Address - Fax:480-656-1231
Practice Address - Street 1:111 S HEARTHSTONE WAY
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-5010
Practice Address - Country:US
Practice Address - Phone:480-239-3459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility