Provider Demographics
NPI:1760526669
Name:CHAN, LIDER (DPT)
Entity Type:Individual
Prefix:DR
First Name:LIDER
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10921 WILSHIRE BLVD STE 1208
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4005
Mailing Address - Country:US
Mailing Address - Phone:626-428-5658
Mailing Address - Fax:
Practice Address - Street 1:10921 WILSHIRE BLVD STE 1208
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4005
Practice Address - Country:US
Practice Address - Phone:424-260-2974
Practice Address - Fax:424-260-2980
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29818225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT29818OtherSTATE LICENSE