Healthcare Provider Details

I. General information

NPI: 1922364900
Provider Name (Legal Business Name): ELI J KO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E YORBA LINDA BLVD STE 5C
PLACENTIA CA
92870-3006
US

IV. Provider business mailing address

1440 N HARBOR BLVD STE 900
FULLERTON CA
92835-4122
US

V. Phone/Fax

Practice location:
  • Phone: 714-869-7025
  • Fax:
Mailing address:
  • Phone: 714-869-7025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT94549
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: