Healthcare Provider Details

I. General information

NPI: 1467256768
Provider Name (Legal Business Name): ROBERT CONNORS RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2025
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13222 CHAPMAN AVE
GARDEN GROVE CA
92840-4414
US

IV. Provider business mailing address

17326 SANTA ISABEL ST
FOUNTAIN VALLEY CA
92708-3111
US

V. Phone/Fax

Practice location:
  • Phone: 310-780-1667
  • Fax:
Mailing address:
  • Phone: 516-551-6988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberR1606100425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: