Healthcare Provider Details

I. General information

NPI: 1396958492
Provider Name (Legal Business Name): MRS. MILDRED Q TAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13565 MONTE ROYALE DR
CHINO HILLS CA
91709-1381
US

IV. Provider business mailing address

13565 MONTE ROYALE DR
CHINO HILLS CA
91709-1381
US

V. Phone/Fax

Practice location:
  • Phone: 909-627-1782
  • Fax:
Mailing address:
  • Phone: 909-627-1782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License NumberMTA18571
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: