Provider Demographics
NPI:1962555466
Name:THERESA CHINN, M.D., INC.
Entity type:Organization
Organization Name:THERESA CHINN, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHINN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-766-2110
Mailing Address - Street 1:12660 RIVERSIDE DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3429
Mailing Address - Country:US
Mailing Address - Phone:818-766-2110
Mailing Address - Fax:818-508-1648
Practice Address - Street 1:12660 RIVERSIDE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-3429
Practice Address - Country:US
Practice Address - Phone:818-766-2110
Practice Address - Fax:818-508-1648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81054207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G810540Medicaid
CA00G810540Medicaid