MEDICARE: MISS CECILIA TAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist	853402	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	853402	OTHER	CA	REGISTRATION NUMBER

General Provider Information

NPI Number	:	1033276886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CECILIA TAM

Provider Business Mailing Address
First Line	:	PO BOX 1020
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95201-3120
Country	:	US
Telephone Number	:	209-468-6000
Fax Number	:	209-468-7042

Provider Business Practice Location Address
First Line	:	500 W. HOSPITAL RD.
Second Line	:
City	:	FRENCH CAMP
State	:	CA
Zip	:	95231-9989
Country	:	US
Telephone Number	:	209-468-6000
Fax Number	:	209-468-7042

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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Directions to “ MISS CECILIA TAM ” Practice Location

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