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General NPI Number Information
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NPI Number | 1558467225
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Entity Type | Organization
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Legal Business Name | MARSHALL B. KETCHUM UNIVERSITY/UNIVERSITY EYE CENTER AT LOS ANGELES
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Dates
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Enumeration Date | 09/16/2006
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Last Update Date | 10/08/2015
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Provider Practice Location Address
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Address Line | 3916 S. BROADWAY
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City | LOS ANGELES
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State | CA
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Zip | 90037
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Country | US
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Telephone | 323-234-9137
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Fax | 323-235-6203
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Provider Business Mailing Address
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Address Line | 3916 S. BROADWAY
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City | LOS ANGELES
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State | CA
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Zip | 90037
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Country | US
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Telephone | 323-234-9137
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Fax | 323-235-6203
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | MARK E. NAKENO
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Credential | O.D.
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Telephone | 323-234-9137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 5827 TPL
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State | CA
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