Provider Demographics
NPI:1114541216
Name:CHA, TAEKYUNG
Entity Type:Individual
Prefix:
First Name:TAEKYUNG
Middle Name:
Last Name:CHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 N ISADORA WAY
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-2329
Mailing Address - Country:US
Mailing Address - Phone:701-202-4296
Mailing Address - Fax:
Practice Address - Street 1:1308 N ISADORA WAY
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-2329
Practice Address - Country:US
Practice Address - Phone:701-202-4296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95191803163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse