Healthcare Provider Details

I. General information

NPI: 1992872691
Provider Name (Legal Business Name): JOAN KEDDINGTON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 03/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 E PLAZA BLVD
NATIONAL CITY CA
91950-3613
US

IV. Provider business mailing address

1773 COUNTRY VISTAS LN
BONITA CA
91902-3076
US

V. Phone/Fax

Practice location:
  • Phone: 619-477-2159
  • Fax: 619-477-2128
Mailing address:
  • Phone: 619-421-8929
  • Fax: 619-271-6315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6263T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: