Healthcare Provider Details

I. General information

NPI: 1568612604
Provider Name (Legal Business Name): DEAN RICHARD TABER CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2008
Last Update Date: 09/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10767 JAMACHA BLVD SPC 142
SPRING VALLEY CA
91978-1859
US

IV. Provider business mailing address

10767 JAMACHA BLVD SPC 142
SPRING VALLEY CA
91978-1859
US

V. Phone/Fax

Practice location:
  • Phone: 619-254-9983
  • Fax:
Mailing address:
  • Phone: 619-254-9983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberTCH 14036
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: