Healthcare Provider Details

I. General information

NPI: 1134367840
Provider Name (Legal Business Name): LORETTA DOLORES CHACON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S 2ND AVE SUITE 7
COVINA CA
91723-3017
US

IV. Provider business mailing address

2467 GEHRIG ST B
WEST COVINA CA
91792-4776
US

V. Phone/Fax

Practice location:
  • Phone: 626-974-8122
  • Fax:
Mailing address:
  • Phone: 626-581-1601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: