Provider Demographics
NPI:1558619593
Name:MERRILL, KENNETH E
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:MERRILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 AVENIDA PICO
Mailing Address - Street 2:STE C-602
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6957
Mailing Address - Country:US
Mailing Address - Phone:714-898-7027
Mailing Address - Fax:
Practice Address - Street 1:100 WESTMINSTER MALL
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-4936
Practice Address - Country:US
Practice Address - Phone:714-898-7027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-23
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA7318237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist