=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689701807
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDY YI-SHUAN LAI MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 12/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 375 HUNTINGTON DR STE F
-----------------------------------------------------
City | SAN MARINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91108-2357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-270-1580
-----------------------------------------------------
Fax | 626-399-0478
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 730
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91785-0730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-256-6010
-----------------------------------------------------
Fax | 855-898-4054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | A67557
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------