Healthcare Provider Details

I. General information

NPI: 1700243763
Provider Name (Legal Business Name): TRUNG HA QUACH AT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 W POSADA LN
MOUNTAIN HOUSE CA
95391-2041
US

IV. Provider business mailing address

63 W POSADA LANE
MOUNTAIN HOUSE CA
95391
US

V. Phone/Fax

Practice location:
  • Phone: 209-817-3735
  • Fax:
Mailing address:
  • Phone: 209-817-3735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberNBC-22621
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: