Healthcare Provider Details

I. General information

NPI: 1285597831
Provider Name (Legal Business Name): TIFFANY GILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 AVENIDA SAN DIMAS
SAN CLEMENTE CA
92672-3421
US

IV. Provider business mailing address

33601 RISING TIDE CT
DANA POINT CA
92629-1924
US

V. Phone/Fax

Practice location:
  • Phone: 949-354-1020
  • Fax:
Mailing address:
  • Phone: 949-354-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZA2600X
TaxonomyMedical Art Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: