=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558683383
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIOCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2010
-----------------------------------------------------
Last Update Date | 02/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8608 UTICA AVE SUITE 220
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-4877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-347-2426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8608 UTICA AVE SUITE 220
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-4877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-347-2426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. TANISHA N ROBERTS
-----------------------------------------------------
Credential | R.T
-----------------------------------------------------
Telephone | 951-347-2426
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 227800000X
-----------------------------------------------------
Taxonomy Name | Certified Respiratory Therapist
-----------------------------------------------------
License Number | 00020103
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------