1720554983 NPI number — SHAY TING DAPHNE TAN PT, DPT

Table of content: SHAY TING DAPHNE TAN PT, DPT (NPI 1720554983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720554983 NPI number — SHAY TING DAPHNE TAN PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAN
Provider First Name:
SHAY TING
Provider Middle Name:
DAPHNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TAN
Provider Other First Name:
DAPHNE
Provider Other Middle Name:
SHAY TING
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1720554983
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3754 MERCURY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90031-2127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 VISTA AVE STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91107-3699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-365-1380
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/15/2018

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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