1922080720 NPI number — RACHELLE MARIE KELTNER EDSTROM O.D.

Table of content: RACHELLE MARIE KELTNER EDSTROM O.D. (NPI 1922080720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922080720 NPI number — RACHELLE MARIE KELTNER EDSTROM O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDSTROM
Provider First Name:
RACHELLE
Provider Middle Name:
MARIE KELTNER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELTNER
Provider Other First Name:
RACHELLE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922080720
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13173 BLACK MOUNTAIN RD
Provider Second Line Business Mailing Address:
SUITE 7
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92129-2687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-538-6695
Provider Business Mailing Address Fax Number:
858-538-3182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13173 BLACK MOUNTAIN RD
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92129-2687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-538-6695
Provider Business Practice Location Address Fax Number:
858-538-3182
Provider Enumeration Date:
11/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT 11900TPG , 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)





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