=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407442502
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN JAMES TAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2020
-----------------------------------------------------
Last Update Date | 12/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31248 OAK CREST DR STE 120
-----------------------------------------------------
City | WESTLAKE VILLAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91361-5673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-538-5880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4713 AMBRUZZI DR
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90630-3530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-943-5351
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 21634
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------