Provider Demographics
NPI:1538617345
Name:TATUM, CHRONDARIUS
Entity type:Individual
Prefix:MR
First Name:CHRONDARIUS
Middle Name:
Last Name:TATUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 KENDALL DR APT 87
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-2859
Mailing Address - Country:US
Mailing Address - Phone:909-771-9712
Mailing Address - Fax:
Practice Address - Street 1:1660 KENDALL DR APT 87
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-2859
Practice Address - Country:US
Practice Address - Phone:909-771-9712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M0000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator