Healthcare Provider Details

I. General information

NPI: 1003033754
Provider Name (Legal Business Name): GLORY CABANILLA TANCINCO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6245 DE LONGPRE AVE
LOS ANGELES CA
90028-8253
US

IV. Provider business mailing address

PO BOX 60790
PASADENA CA
91116-6790
US

V. Phone/Fax

Practice location:
  • Phone: 234-622-2713
  • Fax:
Mailing address:
  • Phone:
  • Fax: 213-413-0327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberC50519
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberC50519
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: