| Keystone | |
|
4449 Easton Way Ste 200 Columbus OH 43219-7005 | |
| (614) 208-4973 | |
| (888) 858-4293 |
| Full Name | Keystone |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 4449 Easton Way Ste 200, Columbus, Ohio |
| Authorized Official Name and Position | Khalilah Krystal Larue (CERTFIED NURSE PRACTITIONER) |
| Authorized Official Contact | 6146682149 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Keystone 4449 Easton Way Ste 200 Columbus OH 43219-7005 Ph: (614) 208-4973 | Keystone 4449 Easton Way Ste 200 Columbus OH 43219-7005 Ph: (614) 208-4973 |
| NPI Number | 1396276432 |
|---|---|
| Provider Enumeration Date | 03/21/2017 |
| Last Update Date | 07/02/2024 |
| Certification Date | 07/02/2024 |
| Medicare PECOS PAC ID | 8921385139 |
|---|---|
| Medicare Enrollment ID | O20170425002646 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1396276432 | NPI | - | NPPES |
| 0076744 | Medicaid | OH | |
| 003260122B | Medicaid | GA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | 10483 (Ohio) | Primary |
| Provider Name | Khalilah K Larue |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1255578548 PECOS PAC ID: 7315123692 Enrollment ID: I20110523000041 |
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