Healthcare Provider Details

I. General information

NPI: 1295372621
Provider Name (Legal Business Name): KEEBAN NAM, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23141 MOULTON PKWY STE 213
LAGUNA HILLS CA
92653-1204
US

IV. Provider business mailing address

1508 BARTON RD # 325
REDLANDS CA
92373-1410
US

V. Phone/Fax

Practice location:
  • Phone: 714-794-9725
  • Fax: 617-607-4064
Mailing address:
  • Phone: 714-794-9725
  • Fax: 617-607-4064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. KEEBAN CALEB NAM
Title or Position: PRESIDENT
Credential: MD
Phone: 714-794-9725