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General NPI Number Information
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NPI Number | 1942570130
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Entity Type | Organization
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Legal Business Name | TYD EXECUTIVE MEDICAL CLINIC
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Dates
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Enumeration Date | 01/05/2012
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Last Update Date | 04/24/2014
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Provider Practice Location Address
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Address Line | 411 N CENTRAL AVE STE 305
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City | GLENDALE
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State | CA
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Zip | 91203-2020
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Country | US
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Telephone | 818-500-0205
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Fax | 818-500-1348
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Provider Business Mailing Address
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Address Line | 411 N CENTRAL AVE STE 305
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City | GLENDALE
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State | CA
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Zip | 91203-2020
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Country | US
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Telephone | 818-500-0205
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Fax | 818-500-1348
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Authorized Official
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Title or Position | PHYSICIAN
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Name | TZE YU DANG
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Credential | M.D
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Telephone | 818-500-0205
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | G44887
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License Number State | CA
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