Basic Information
Provider Information | |||||||||
NPI: | 1356823207 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GIORDANO | ||||||||
FirstName: | TINA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26830 HOSTETTLER RD | ||||||||
Address2: |   | ||||||||
City: | CORONA | ||||||||
State: | CA | ||||||||
PostalCode: | 928835210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9512509970 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 31764 CASINO DR | ||||||||
Address2: |   | ||||||||
City: | LAKE ELSINORE | ||||||||
State: | CA | ||||||||
PostalCode: | 925304571 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9514714645 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2018 | ||||||||
LastUpdateDate: | 09/06/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 687897 | CA | Y |   | Nursing Service Providers | Licensed Vocational Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 164X00000X | 01 | CA | LICENSED VOVATIONAL NURSE | OTHER | 164XOOOOOX | 01 | CA | COUNTY OF RIVERSIDE | OTHER |