Healthcare Provider Details

I. General information

NPI: 1003512971
Provider Name (Legal Business Name): MR. GLENN PATRICK TAJALLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 EXETER WAY
CORONA CA
92882-8502
US

IV. Provider business mailing address

161 EXETER WAY
CORONA CA
92882-8502
US

V. Phone/Fax

Practice location:
  • Phone: 714-675-9089
  • Fax:
Mailing address:
  • Phone: 714-675-9089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: