Healthcare Provider Details

I. General information

NPI: 1114466521
Provider Name (Legal Business Name): DR. SLIMAN COSTA TANNOUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2017
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5478 WILSHIRE BLVD STE 208
LOS ANGELES CA
90036-4225
US

IV. Provider business mailing address

PO BOX 1950
LAKEPORT CA
95453-1950
US

V. Phone/Fax

Practice location:
  • Phone: 323-936-7525
  • Fax:
Mailing address:
  • Phone: 707-263-8383
  • Fax: 707-263-5019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number292841
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: