Healthcare Provider Details

I. General information

NPI: 1053075630
Provider Name (Legal Business Name): CHRISTOPHER TJU OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6177 RIVER CREST DR STE A
RIVERSIDE CA
92507-0728
US

IV. Provider business mailing address

6177 RIVER CREST DR STE A
RIVERSIDE CA
92507-0728
US

V. Phone/Fax

Practice location:
  • Phone: 951-653-4480
  • Fax: 951-653-5051
Mailing address:
  • Phone: 951-653-4480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number21830
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: