Healthcare Provider Details

I. General information

NPI: 1568968899
Provider Name (Legal Business Name): CONRADO OLALIA QUEMUEL CRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 09/28/2024
Certification Date: 09/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 PREBLE DR
TUSTIN CA
92780-3720
US

IV. Provider business mailing address

17282 AMAGANSET WAY
TUSTIN CA
92780-2506
US

V. Phone/Fax

Practice location:
  • Phone: 714-474-1149
  • Fax:
Mailing address:
  • Phone: 714-474-1149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberRHF00097408
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: