Healthcare Provider Details

I. General information

NPI: 1619163870
Provider Name (Legal Business Name): IAN CHWEN HSIEN GOH OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 BONITA RD STE 100
CHULA VISTA CA
91910-3263
US

IV. Provider business mailing address

8550 COSTA VERDE BLVD APT 5418
SAN DIEGO CA
92122-1177
US

V. Phone/Fax

Practice location:
  • Phone: 619-585-7104
  • Fax: 619-585-7106
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT9271
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225XE1200X
TaxonomyErgonomics Occupational Therapist
License NumberOT9271
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT9271
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: