Healthcare Provider Details

I. General information

NPI: 1255744462
Provider Name (Legal Business Name): REBECCA KENKEL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 DEEP VALLEY DR STE 311
ROLLING HILLS ESTATES CA
90274-3655
US

IV. Provider business mailing address

827 DEEP VALLEY DR STE 311
ROLLING HILLS ESTATES CA
90274-3655
US

V. Phone/Fax

Practice location:
  • Phone: 310-541-3411
  • Fax:
Mailing address:
  • Phone: 408-499-2917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14908TLG
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14908
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: