Provider Demographics
NPI:1407442502
Name:TAN, KEVIN JAMES
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JAMES
Last Name:TAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4713 AMBRUZZI DR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-3530
Mailing Address - Country:US
Mailing Address - Phone:714-943-5351
Mailing Address - Fax:
Practice Address - Street 1:31248 OAK CREST DR STE 120
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-5673
Practice Address - Country:US
Practice Address - Phone:818-538-5880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21634225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist