Healthcare Provider Details

I. General information

NPI: 1811310378
Provider Name (Legal Business Name): TOMMY NGUYEN BS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 E WASHINGTON ST
CHAMPAIGN IL
61820-3652
US

IV. Provider business mailing address

801 N WALNUT ST
CHAMPAIGN IL
61820-3055
US

V. Phone/Fax

Practice location:
  • Phone: 217-398-7785
  • Fax:
Mailing address:
  • Phone: 217-373-2430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: