=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740508084
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELBA Y TAN OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2010
-----------------------------------------------------
Last Update Date | 05/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 667 PELHAM RD #B6
-----------------------------------------------------
City | NEW ROCHELLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10805-1151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-433-7517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 667 PELHAM RD #B6
-----------------------------------------------------
City | NEW ROCHELLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10805-1151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-433-7517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 012931-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------