Healthcare Provider Details

I. General information

NPI: 1689590002
Provider Name (Legal Business Name): TYSON TRUONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 GATEWAY DR
RIVERSIDE CA
92507-0908
US

IV. Provider business mailing address

527 N 8TH AVE
UPLAND CA
91786-4806
US

V. Phone/Fax

Practice location:
  • Phone: 888-530-4415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number22383
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: