Basic Information
| Provider Information | |||||||||
| NPI: | 1790180453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEEHLER | ||||||||
| FirstName: | TIM | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | RSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CHANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610159732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155017366 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 FAIRVIEW DR | ||||||||
| Address2: | |||||||||
| City: | ROCHELLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610682310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155619003 | ||||||||
| FaxNumber: | 8155626692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2014 | ||||||||
| LastUpdateDate: | 10/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.