=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043762032
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | INTI WING CHAN CMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2016
-----------------------------------------------------
Last Update Date | 10/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 MURRIETA BLVD
-----------------------------------------------------
City | LIVERMORE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94550-4111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-289-4079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 149 LIPTON PL
-----------------------------------------------------
City | SAN RAMON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94583-3422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-289-4079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 31284
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------