Healthcare Provider Details

I. General information

NPI: 1942590286
Provider Name (Legal Business Name): TRACIE EPPS ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8220 S SAN PEDRO ST
LOS ANGELES CA
90003-3030
US

IV. Provider business mailing address

260 LINDA ROSA AVE APT #3
PASADENA CA
91107-3234
US

V. Phone/Fax

Practice location:
  • Phone: 323-565-2363
  • Fax: 323-789-5648
Mailing address:
  • Phone: 626-533-5730
  • 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: