Provider Demographics
NPI:1972650802
Name:KELLER ORTHOTICS INC
Entity type:Organization
Organization Name:KELLER ORTHOTICS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-929-4700
Mailing Address - Street 1:2451 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1509
Mailing Address - Country:US
Mailing Address - Phone:773-929-4700
Mailing Address - Fax:773-929-4725
Practice Address - Street 1:2451 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1509
Practice Address - Country:US
Practice Address - Phone:773-929-4700
Practice Address - Fax:773-929-4725
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KELLER ORTHOTICS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-04
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========004Medicaid
IL=========001Medicaid
IL=========004Medicaid