=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740708650
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIEN DUC PHAM DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2017
-----------------------------------------------------
Last Update Date | 08/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8933 ACTIVITY RD
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92126-4427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-499-2600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10305 PARKDALE AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92126-3451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-329-9372
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT42592
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------