Provider Demographics
NPI:1376214395
Name:TAN, TAMMY MIN (LAC)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:MIN
Last Name:TAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1013
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91793-1013
Mailing Address - Country:US
Mailing Address - Phone:818-928-9128
Mailing Address - Fax:
Practice Address - Street 1:3119 SAN GABRIEL BLVD STE D
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-2545
Practice Address - Country:US
Practice Address - Phone:818-928-9128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18987171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist