Provider Demographics
NPI:1558467225
Name:MARSHALL B. KETCHUM UNIVERSITY/UNIVERSITY EYE CENTER AT LOS ANGELES
Entity Type:Organization
Organization Name:MARSHALL B. KETCHUM UNIVERSITY/UNIVERSITY EYE CENTER AT LOS ANGELES
Other - Org Name:OPTOMETRIC CENTER OF LOS ANGELES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:NAKENO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:323-234-9137
Mailing Address - Street 1:3916 S. BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037
Mailing Address - Country:US
Mailing Address - Phone:323-234-9137
Mailing Address - Fax:323-235-6203
Practice Address - Street 1:3916 S. BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037
Practice Address - Country:US
Practice Address - Phone:323-234-9137
Practice Address - Fax:323-235-6203
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARSHALL B. KETCHUM UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-16
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5827 TPL152W00000X
CA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT11740FMedicaid
CAZZT 11740FMedicaid
CAZZT11740FMedicaid
CA44593Medicare PIN