Healthcare Provider Details

I. General information

NPI: 1255896379
Provider Name (Legal Business Name): TIMOTHY LAMBENGCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2019
Last Update Date: 02/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W PROVIDENCE AVE
ORANGE CA
92868-3808
US

IV. Provider business mailing address

1301 W PROVIDENCE AVE
ORANGE CA
92868-3808
US

V. Phone/Fax

Practice location:
  • Phone: 714-639-4990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number19428
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: