Healthcare Provider Details

I. General information

NPI: 1215854781
Provider Name (Legal Business Name): ETHAN DU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2026
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N MOUNTAIN AVE STE 100
UPLAND CA
91786-5194
US

IV. Provider business mailing address

3100 GARDENIA LN
YORBA LINDA CA
92886-1878
US

V. Phone/Fax

Practice location:
  • Phone: 909-596-4346
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number550205
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: