Provider Demographics
NPI:1992755961
Name:KEBO, LARRY (OD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:KEBO
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 1:1400 JENSEN AVE
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:CA
Mailing Address - Zip Code:93657-2413
Mailing Address - Country:US
Mailing Address - Phone:559-875-4515
Mailing Address - Fax:
Practice Address - Street 1:1400 JENSEN AVE
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:CA
Practice Address - Zip Code:93657-2413
Practice Address - Country:US
Practice Address - Phone:559-875-4515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6262T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0062620Medicaid
CA49154OtherSAFEGUARD
CA1449OtherMEDICAL EYE SERVICES
CA116578OtherEYE MED
CASD0062620Medicaid
CA116578OtherEYE MED