Provider Demographics
NPI:1043836190
Name:KELLER, LAURA (OD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1242
Mailing Address - Country:US
Mailing Address - Phone:989-463-1139
Mailing Address - Fax:
Practice Address - Street 1:2865 S LINCOLN RD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-9085
Practice Address - Country:US
Practice Address - Phone:989-773-7747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005441152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist