Basic Information
Provider Information
NPI: 1417696964
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CHU
FirstName: DANA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7324 FIELDRUSH CT
Address2:  
City: FONTANA
State: CA
PostalCode: 923363188
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1007 E COOLEY DR
Address2:  
City: COLTON
State: CA
PostalCode: 923243901
CountryCode: US
TelephoneNumber: 7608370033
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/02/2022
LastUpdateDate: 06/02/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 05/31/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  Y    

ID Information
IDTypeStateIssuerDescription
00002318149501 KAISEROTHER


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