Provider Demographics
NPI:1568913671
Name:PRO SPORTS INSTITUTE A MEDICAL CORPORATION INC
Entity Type:Organization
Organization Name:PRO SPORTS INSTITUTE A MEDICAL CORPORATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:TAN
Authorized Official - Last Name:DEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-408-5345
Mailing Address - Street 1:7677 CENTER AVE
Mailing Address - Street 2:SUITE 403
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3074
Mailing Address - Country:US
Mailing Address - Phone:714-379-9355
Mailing Address - Fax:714-379-5402
Practice Address - Street 1:7677 CENTER AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3074
Practice Address - Country:US
Practice Address - Phone:714-379-9355
Practice Address - Fax:714-379-5402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23165111N00000X
CA65423207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty