Healthcare Provider Details

I. General information

NPI: 1215537543
Provider Name (Legal Business Name): GEREINE MAE CONDINO DATAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 10/27/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W 190 ST
GARDENA CA
90248
US

IV. Provider business mailing address

25612 BARTON RD # 290
LOMA LINDA CA
92354-3110
US

V. Phone/Fax

Practice location:
  • Phone: 714-452-1961
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF08201140
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: