Provider Demographics
NPI:1790304186
Name:REM, TATYANA (L AC)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:REM
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 SILVER LAKE BVLD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-1221
Mailing Address - Country:US
Mailing Address - Phone:323-662-3109
Mailing Address - Fax:
Practice Address - Street 1:1745 SILVER LAKE BVLD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-1221
Practice Address - Country:US
Practice Address - Phone:323-662-3109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18351261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center