1770843112 NPI number — MR. JEFFREY DULAY CHAN

Table of content: MR. JEFFREY DULAY CHAN (NPI 1770843112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770843112 NPI number — MR. JEFFREY DULAY CHAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAN
Provider First Name:
JEFFREY
Provider Middle Name:
DULAY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770843112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1450 S IMPERIAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL CENTRO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92243-4200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-352-3108
Provider Business Mailing Address Fax Number:
760-352-3234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1605 SCOTT AVE STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CENTRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92243-1790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-352-3108
Provider Business Practice Location Address Fax Number:
760-352-3234
Provider Enumeration Date:
05/18/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WH0200X , with the licence number:  698955 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 95018570 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 95018570 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)