Healthcare Provider Details

I. General information

NPI: 1891556676
Provider Name (Legal Business Name): TIMOTHY LAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17732 BEACH BLVD STE G
HUNTINGTON BEACH CA
92647-6881
US

IV. Provider business mailing address

17732 BEACH BLVD STE G
HUNTINGTON BEACH CA
92647-6881
US

V. Phone/Fax

Practice location:
  • Phone: 714-655-7142
  • Fax:
Mailing address:
  • Phone: 714-655-7142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: