Healthcare Provider Details

I. General information

NPI: 1740137710
Provider Name (Legal Business Name): IAN SAN LUIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2026
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17307 EASTVIEW DR
CHINO HILLS CA
91709-6300
US

IV. Provider business mailing address

17307 EASTVIEW DR
CHINO HILLS CA
91709-6300
US

V. Phone/Fax

Practice location:
  • Phone: 909-438-5006
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95037783
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: