1760716997 NPI number — EDWARD BARRY KEEHN PHD

Table of content: (NPI 1760716997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760716997 NPI number — EDWARD BARRY KEEHN PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWARD BARRY KEEHN PHD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760716997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1447 S CANFIELD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90035-3224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-985-9004
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 S EUCLID AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91101-2717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-578-9565
Provider Business Practice Location Address Fax Number:
626-578-9517
Provider Enumeration Date:
09/21/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KEEHN
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
BARRY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
310-985-9004

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  22069 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22069 . This is a "LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".