MEDICARE: DAVE LYNAEUS TAN P.T.

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	2251X0800X	Orthopedic Physical Therapist	PT8728	CA

General Provider Information

NPI Number	:	1932168655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVE LYNAEUS TAN P.T.

Provider Business Mailing Address
First Line	:	2120 E COLUNGA ST
Second Line	:
City	:	COLTON
State	:	CA
Zip	:	92324-4577
Country	:	US
Telephone Number	:	909-370-1175
Fax Number	:

Provider Business Practice Location Address
First Line	:	11406 LOMA LINDA DR
Second Line	:	WEST ENTRANCE
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-3711
Country	:	US
Telephone Number	:	909-558-6501
Fax Number	:	909-558-6002

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

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	12/23/2013

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