Healthcare Provider Details

I. General information

NPI: 1194226969
Provider Name (Legal Business Name): IMMA TIJANI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 02/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 DELTA FAIR BLVD
ANTIOCH CA
94509-4001
US

IV. Provider business mailing address

21600 OXNARD ST STE 1800
WOODLAND HILLS CA
91367-7807
US

V. Phone/Fax

Practice location:
  • Phone: 925-709-6060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: