Provider Demographics
NPI:1801135702
Name:TANCHOCO CHILDREN AND ADOLESCENT CLINIC, INC.
Entity type:Organization
Organization Name:TANCHOCO CHILDREN AND ADOLESCENT CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:IMELDA
Authorized Official - Middle Name:TAN
Authorized Official - Last Name:TANCHOCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-960-2977
Mailing Address - Street 1:1535 W MERCED AVE
Mailing Address - Street 2:STE. 306
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3404
Mailing Address - Country:US
Mailing Address - Phone:626-960-2977
Mailing Address - Fax:626-960-2979
Practice Address - Street 1:1535 W MERCED AVE
Practice Address - Street 2:STE. 306
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3404
Practice Address - Country:US
Practice Address - Phone:626-960-2977
Practice Address - Fax:626-960-2979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106359261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care