Healthcare Provider Details

I. General information

NPI: 1760526669
Provider Name (Legal Business Name): LIDER CHAN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10921 WILSHIRE BLVD STE 1208
LOS ANGELES CA
90024-4005
US

IV. Provider business mailing address

10921 WILSHIRE BLVD STE 1208
LOS ANGELES CA
90024-4005
US

V. Phone/Fax

Practice location:
  • Phone: 424-260-2974
  • Fax: 424-260-2980
Mailing address:
  • Phone: 626-428-5658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT29818
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: