Healthcare Provider Details

I. General information

NPI: 1720328727
Provider Name (Legal Business Name): CHRISTOPHER V TAN PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 LAKE ALFRED RD
WINTER HAVEN FL
33881-1432
US

IV. Provider business mailing address

613 GOLF COURSE PKWY
DAVENPORT FL
33837-5529
US

V. Phone/Fax

Practice location:
  • Phone: 863-298-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT12179
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: