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General NPI Number Information
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NPI Number | 1174824221
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Entity Type | Organization
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Legal Business Name | EDMOND L CHAN MD A MEDICAL CORPORATION
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Dates
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Enumeration Date | 11/05/2010
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Last Update Date | 05/04/2015
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Provider Practice Location Address
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Address Line | 15708 POMERADO RD # N107
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City | POWAY
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State | CA
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Zip | 92064-2066
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Country | US
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Telephone | 858-485-5921
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Fax | 858-485-1445
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Provider Business Mailing Address
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Address Line | 15708 POMERADO RD # N107
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City | POWAY
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State | CA
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Zip | 92064-2066
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Country | US
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Telephone | 858-485-5921
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Fax | 858-485-1445
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | VERONICA A RENTERIA
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Credential |
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Telephone | 858-485-5921
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | A89731
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License Number State | CA
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