=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053638601
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIFFANY ANDERSON TERRELL, DO. INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2010
-----------------------------------------------------
Last Update Date | 11/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5253 RIVERSIDE DR
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-4151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-464-2845
-----------------------------------------------------
Fax | 909-464-2848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13193 CENTRAL AVE SUITE 210
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-4179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-548-4900
-----------------------------------------------------
Fax | 909-548-4904
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. TIFFANY ANDERSON TERRELL
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 909-548-4900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 20A8506
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------