Provider Demographics
NPI:1861456972
Name:PHAN, TUYET BACH (ATC)
Entity Type:Individual
Prefix:MS
First Name:TUYET
Middle Name:BACH
Last Name:PHAN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:MS
Other - First Name:SNOW
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC
Mailing Address - Street 1:2400 CARNEGIE LN
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-3811
Mailing Address - Country:US
Mailing Address - Phone:310-377-1543
Mailing Address - Fax:310-377-0380
Practice Address - Street 1:2400 CARNEGIE LN
Practice Address - Street 2:#2
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3811
Practice Address - Country:US
Practice Address - Phone:310-377-1543
Practice Address - Fax:310-377-0380
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer