Healthcare Provider Details

I. General information

NPI: 1932504925
Provider Name (Legal Business Name): COURTNEY KASSEBAUM BOVY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2014
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5655 E LA PALMA AVE STE 150
ANAHEIM CA
92807-2122
US

IV. Provider business mailing address

5655 E LA PALMA AVE STE 150
ANAHEIM CA
92807-2122
US

V. Phone/Fax

Practice location:
  • Phone: 714-340-0520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT 15011 TLG
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT 15011 TLG
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPT 15011 TLG
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberOPT 15011 TLG
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberOPT 15011 TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: