Provider Demographics
NPI:1992417018
Name:KEYSTONE HEALTHCARE SYSTEMS LLC
Entity type:Organization
Organization Name:KEYSTONE HEALTHCARE SYSTEMS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:SOLOMON
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:901-264-3704
Mailing Address - Street 1:105 WEBSTER ST STE 5
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339-1227
Mailing Address - Country:US
Mailing Address - Phone:901-264-3704
Mailing Address - Fax:
Practice Address - Street 1:105 WEBSTER ST STE 5
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-1227
Practice Address - Country:US
Practice Address - Phone:901-264-3704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1013448620Medicaid
TN1851927511Medicaid