Healthcare Provider Details

I. General information

NPI: 1275299794
Provider Name (Legal Business Name): TINA QUACH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

482 W SAN CARLOS ST
SAN JOSE CA
95110-2627
US

IV. Provider business mailing address

7108 S KANNER HWY
STUART FL
34997-7462
US

V. Phone/Fax

Practice location:
  • Phone: 669-289-3360
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: