Healthcare Provider Details

I. General information

NPI: 1700280849
Provider Name (Legal Business Name): TONNY MWANGANGI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11165 MICHAEL WAY
BEAUMONT CA
92223
US

IV. Provider business mailing address

11165 MICHAEL WAY
BEAUMONT CA
92223-6255
US

V. Phone/Fax

Practice location:
  • Phone: 951-801-2138
  • Fax:
Mailing address:
  • Phone: 951-801-2138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number648795
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: