Provider Demographics
NPI:1952451015
Name:TIENG TAN, O.D. INC
Entity Type:Organization
Organization Name:TIENG TAN, O.D. INC
Other - Org Name:ICU OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIENG
Authorized Official - Middle Name:MENG
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-458-5393
Mailing Address - Street 1:220 W VALLEY BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3738
Mailing Address - Country:US
Mailing Address - Phone:626-458-5393
Mailing Address - Fax:
Practice Address - Street 1:220 W VALLEY BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3738
Practice Address - Country:US
Practice Address - Phone:626-458-5393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 13131 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABX180AMedicare PIN