Provider Demographics
NPI:1932770161
Name:MAYNARD, TIFFANY (CPO)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:F
Credentials:CPO
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:FONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPO
Mailing Address - Street 1:1920 E KATELLA AVE STE I
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-5149
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1920 E KATELLA AVE STE I
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-5149
Practice Address - Country:US
Practice Address - Phone:714-639-7422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO1893222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1518909019OtherMEDI-CAL