Healthcare Provider Details

I. General information

NPI: 1003396177
Provider Name (Legal Business Name): DWIGHT MARSHALL TAN VILLANUEVA RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DWIGHT TAN VILLANUEVA RRT

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 12/01/2021
Certification Date: 11/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 E LA PALMA AVE
ANAHEIM CA
92806-2020
US

IV. Provider business mailing address

18518 BETTY WAY
CERRITOS CA
90703-6320
US

V. Phone/Fax

Practice location:
  • Phone: 714-644-2000
  • Fax:
Mailing address:
  • Phone: 714-684-4257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number25583
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: