MEDICARE: THESEA CHINN MD MPH INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	G81054	CA

General Provider Information

NPI Number	:	1043235625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THESEA CHINN MD MPH INC

Provider Business Mailing Address
First Line	:	12660 RIVERSIDE DR
Second Line	:	STE 110
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91607-3430
Country	:	US
Telephone Number	:	818-766-2110
Fax Number	:	818-508-1463

Provider Business Practice Location Address
First Line	:	12660 RIVERSIDE DR
Second Line	:	STE 110
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91607-3430
Country	:	US
Telephone Number	:	818-766-2110
Fax Number	:	818-508-1463

Authorized Official
Title or Position	:	CEO
Name	:	THERESA CHINN
Credential	:	MD
Telephone Number	:	818-766-2110

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	08/22/2020

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