Healthcare Provider Details

I. General information

NPI: 1164010344
Provider Name (Legal Business Name): MRS. SUSANA CAROLINA CHIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 01/04/2021
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7211 VAN NUYS BLVD
VAN NUYS CA
91405-2256
US

IV. Provider business mailing address

603 PEARL ST
SAN GABRIEL CA
91776-2617
US

V. Phone/Fax

Practice location:
  • Phone: 818-988-2722
  • Fax:
Mailing address:
  • Phone: 323-404-2188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number95012117
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: