Healthcare Provider Details

I. General information

NPI: 1417636325
Provider Name (Legal Business Name): DYLAN LAU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 N BELLFLOWER BLVD
LONG BEACH CA
90840-0004
US

IV. Provider business mailing address

665 BONNIE CLAIRE DR
WALNUT CA
91789-4196
US

V. Phone/Fax

Practice location:
  • Phone: 562-985-4111
  • Fax:
Mailing address:
  • Phone: 626-823-4889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: