Provider Demographics
NPI:1235771643
Name:KUEPPERS, XALEESE EVELYN (CST)
Entity Type:Individual
Prefix:
First Name:XALEESE
Middle Name:EVELYN
Last Name:KUEPPERS
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23808 BRESCIA DR
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91354-3000
Mailing Address - Country:US
Mailing Address - Phone:310-691-5411
Mailing Address - Fax:
Practice Address - Street 1:12265 VENTURA BLVD STE 107
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2530
Practice Address - Country:US
Practice Address - Phone:310-691-5411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA152799OtherSURGICAL TECHNOLOGIST