Healthcare Provider Details

I. General information

NPI: 1205310539
Provider Name (Legal Business Name): SUYANTO JUJUN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2018
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 E LA PALMA AVE
ANAHEIM CA
92806-2020
US

IV. Provider business mailing address

3440 E LA PALMA AVE
ANAHEIM CA
92806-2020
US

V. Phone/Fax

Practice location:
  • Phone: 714-644-7570
  • Fax:
Mailing address:
  • Phone: 714-644-7570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number18876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: