Healthcare Provider Details

I. General information

NPI: 1124940036
Provider Name (Legal Business Name): TANAKA NHONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 MELBOURNE PL
RIVERSIDE CA
92508-6055
US

IV. Provider business mailing address

5310 MELBOURNE PL
RIVERSIDE CA
92508-6055
US

V. Phone/Fax

Practice location:
  • Phone: 951-367-9657
  • Fax:
Mailing address:
  • Phone: 951-367-9657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: