Provider Demographics
NPI:1861182990
Name:TABIL, KINN JAMES TAGARDA
Entity type:Individual
Prefix:
First Name:KINN JAMES
Middle Name:TAGARDA
Last Name:TABIL
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 1:6428 BLUEBELL ST
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-0736
Mailing Address - Country:US
Mailing Address - Phone:951-416-9551
Mailing Address - Fax:
Practice Address - Street 1:405 W 5TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4599
Practice Address - Country:US
Practice Address - Phone:714-834-5414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95212525163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse