Provider Demographics
NPI:1164010344
Name:CHIA, SUSANA CAROLINA
Entity Type:Individual
Prefix:MRS
First Name:SUSANA
Middle Name:CAROLINA
Last Name:CHIA
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 1:603 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-2617
Mailing Address - Country:US
Mailing Address - Phone:323-404-2188
Mailing Address - Fax:
Practice Address - Street 1:7211 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2256
Practice Address - Country:US
Practice Address - Phone:818-988-2722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012117261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care