Healthcare Provider Details

I. General information

NPI: 1457017618
Provider Name (Legal Business Name): TIMOTHY ROYER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2021
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ALESSANDRO PL STE 410
PASADENA CA
91105-3175
US

IV. Provider business mailing address

60525 YUCCA RD # 264
MOUNTAIN CENTER CA
92561-3745
US

V. Phone/Fax

Practice location:
  • Phone: 626-793-7114
  • Fax:
Mailing address:
  • Phone: 760-832-0301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95018882
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: