Provider Demographics
NPI:1730169897
Name:KELLER, GLEN E (DC)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:E
Last Name:KELLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 LANCASTER NEWARK RD NE
Mailing Address - Street 2:
Mailing Address - City:MILLERSPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43046-8003
Mailing Address - Country:US
Mailing Address - Phone:740-467-2486
Mailing Address - Fax:740-467-2498
Practice Address - Street 1:10400 LANCASTER NEWARK RD NE
Practice Address - Street 2:
Practice Address - City:MILLERSPORT
Practice Address - State:OH
Practice Address - Zip Code:43046-8003
Practice Address - Country:US
Practice Address - Phone:740-467-2486
Practice Address - Fax:740-467-2498
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3369111N00000X
IDCHIA 576111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH665855OtherAMERICAN CHIRO NTWRK(ACN)
OH000000509974OtherBLUE CROSS
OH11176716OtherCAQH
OH2474059Medicaid
OH1003201OtherAMERICAN SPECIALTY HEALTH
OH5585251OtherAETNA
OH4124242Medicare PIN