Provider Demographics
NPI:1427665090
Name:TANTIONGCO, EGBERT (PSYCH TECH, RN)
Entity type:Individual
Prefix:
First Name:EGBERT
Middle Name:
Last Name:TANTIONGCO
Suffix:
Gender:M
Credentials:PSYCH TECH, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 E WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-3549
Mailing Address - Country:US
Mailing Address - Phone:310-938-3215
Mailing Address - Fax:
Practice Address - Street 1:1460 E WILLOW ST
Practice Address - Street 2:
Practice Address - City:SIGNAL HILL
Practice Address - State:CA
Practice Address - Zip Code:90755-3549
Practice Address - Country:US
Practice Address - Phone:310-938-3215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40362167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician