Provider Demographics
NPI:1265054589
Name:LE, TIN TRUNG
Entity type:Individual
Prefix:
First Name:TIN
Middle Name:TRUNG
Last Name:LE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18674 SAN FELIPE ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7121
Mailing Address - Country:US
Mailing Address - Phone:714-600-7083
Mailing Address - Fax:714-242-1599
Practice Address - Street 1:18674 SAN FELIPE ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7121
Practice Address - Country:US
Practice Address - Phone:714-600-7083
Practice Address - Fax:714-242-1599
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306005623310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility