Healthcare Provider Details

I. General information

NPI: 1245700566
Provider Name (Legal Business Name): TYRETEL IANCU DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 LEMON ST
RIVERSIDE CA
92501-2861
US

IV. Provider business mailing address

43130 CHRISTOPHER LN
BANNING CA
92220-1599
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-8202
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: