Healthcare Provider Details

I. General information

NPI: 1043546112
Provider Name (Legal Business Name): IMELDA TAN TANCHOCO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2009
Last Update Date: 10/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21324 STOCKTON PASS RD
WALNUT CA
91789-5111
US

IV. Provider business mailing address

21324 STOCKTON PASS RD
WALNUT CA
91789-5111
US

V. Phone/Fax

Practice location:
  • Phone: 626-233-4964
  • Fax:
Mailing address:
  • Phone: 626-233-4964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA106359
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: