=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467216473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOSEPH CHAN CORP CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2024
-----------------------------------------------------
Last Update Date | 02/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5562 PHILADELPHIA ST STE 200
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-2482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-464-9119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19629 BOMAR CT
-----------------------------------------------------
City | ROWLAND HEIGHTS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91748-3267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-630-8431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSEPH CHAN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 909-630-8431
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------