Healthcare Provider Details

I. General information

NPI: 1609578681
Provider Name (Legal Business Name): BRIAN TAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26700 TOWNE CENTRE DR STE 110
FOOTHILL RANCH CA
92610-2852
US

IV. Provider business mailing address

26700 TOWNE CENTRE DR STE 110
FOOTHILL RANCH CA
92610-2852
US

V. Phone/Fax

Practice location:
  • Phone: 760-396-8526
  • Fax:
Mailing address:
  • Phone: 949-297-4561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number49919
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: