1619012648 NPI number — MARY GRACE TAN D.P.T.

Table of content: MARY GRACE TAN D.P.T. (NPI 1619012648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619012648 NPI number — MARY GRACE TAN D.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAN
Provider First Name:
MARY
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619012648
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13284 WENTWORTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91331-5822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-994-9266
Provider Business Mailing Address Fax Number:
626-576-5890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 S RAYMOND AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
ALHAMBRA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91801-7100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-576-0591
Provider Business Practice Location Address Fax Number:
626-576-5890
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 33405 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PT 33405 . This is a "PHYSICAL THERAPY LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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