Provider Demographics
NPI:1548344146
Name:EKELUND, KENNETH ERROL (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ERROL
Last Name:EKELUND
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 HEMSTED DR STE 110
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-0935
Mailing Address - Country:US
Mailing Address - Phone:530-221-0726
Mailing Address - Fax:530-221-1377
Practice Address - Street 1:310 HEMSTED DR STE 110
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-0935
Practice Address - Country:US
Practice Address - Phone:530-221-0726
Practice Address - Fax:530-221-1377
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 5847T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA942773840OtherTAX IDENTIFICATION
CASD0058470Medicare ID - Type Unspecified
CAT10140Medicare UPIN