Healthcare Provider Details

I. General information

NPI: 1720101876
Provider Name (Legal Business Name): MARSHALL B. KETCHUM UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5460 E LA PALMA AVE
ANAHEIM CA
92807-2023
US

IV. Provider business mailing address

5460 E LA PALMA AVE
ANAHEIM CA
92807-2023
US

V. Phone/Fax

Practice location:
  • Phone: 714-463-7500
  • Fax: 714-992-7811
Mailing address:
  • Phone: 714-463-7500
  • Fax: 714-992-7811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MARK NAKANO
Title or Position: ASSOCIATE DEAN OF CLINICS
Credential: O.D.
Phone: 714-463-7504