Healthcare Provider Details

I. General information

NPI: 1609747435
Provider Name (Legal Business Name): MR. SIMON K CHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15576 TETLEY ST
HACIENDA HTS CA
91745-4502
US

IV. Provider business mailing address

15576 TETLEY ST
HACIENDA HTS CA
91745-4502
US

V. Phone/Fax

Practice location:
  • Phone: 866-525-3175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number305421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: