Healthcare Provider Details

I. General information

NPI: 1306014758
Provider Name (Legal Business Name): MR. EMILIO CHAN EDQUILANG JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34425 FARENHOLT AVENUE SUITE 40, BLDG. 26-2B
SAN DIEGO CA
92134-7040
US

IV. Provider business mailing address

34425 FARENHOLT AVENUE SUITE 40, BLDG. 26-2B
SAN DIEGO CA
92134-7040
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-7141
  • Fax: 619-532-7337
Mailing address:
  • Phone: 619-532-7141
  • Fax: 619-532-7337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License NumberMTA35936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: