Healthcare Provider Details

I. General information

NPI: 1639871965
Provider Name (Legal Business Name): EDWARD LEE KEDDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12291 WASHINGTON BLVD
WHITTIER CA
90606-2500
US

IV. Provider business mailing address

314 GEORGE ST SW
VIENNA VA
22180-6708
US

V. Phone/Fax

Practice location:
  • Phone: 562-698-0811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: