=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922888734
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANALUCK MAXIMILIAN MANOJIT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2023
-----------------------------------------------------
Last Update Date | 09/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6032 VILLAGE RD
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90713-3129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-338-8078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 N ROSE DR # 337
-----------------------------------------------------
City | PLACENTIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92870-7513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-338-8078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------