Provider Demographics
NPI:1407910573
Name:MANELL, KENNETH R (OD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:MANELL
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 1:251 E 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4901
Mailing Address - Country:US
Mailing Address - Phone:760-745-5412
Mailing Address - Fax:
Practice Address - Street 1:251 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4901
Practice Address - Country:US
Practice Address - Phone:760-745-5412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4949T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGDS001100Medicaid
CAT69971Medicare UPIN
CAGDS001100Medicaid