Healthcare Provider Details

I. General information

NPI: 1619507514
Provider Name (Legal Business Name): ALVIN TAN OD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2020
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 W COLORADO ST
GLENDALE CA
91204-1504
US

IV. Provider business mailing address

454 W COLORADO ST
GLENDALE CA
91204-1504
US

V. Phone/Fax

Practice location:
  • Phone: 818-484-7905
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: ALVIN TAN
Title or Position: PRESIDENT
Credential:
Phone: 916-205-8392