MEDICARE: DR. LIDER CHAN DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT29818	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT29818	OTHER	CA	STATE LICENSE

General Provider Information

NPI Number	:	1760526669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LIDER CHAN DPT

Provider Business Mailing Address
First Line	:	10921 WILSHIRE BLVD STE 1208
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-4005
Country	:	US
Telephone Number	:	626-428-5658
Fax Number	:

Provider Business Practice Location Address
First Line	:	10921 WILSHIRE BLVD STE 1208
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-4005
Country	:	US
Telephone Number	:	424-260-2974
Fax Number	:	424-260-2980

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	02/09/2022

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Directions to “ DR. LIDER CHAN DPT” Practice Location

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