Provider Demographics
NPI:1265612345
Name:TAN, EDSEL (LAC)
Entity type:Individual
Prefix:MR
First Name:EDSEL
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2061
Mailing Address - Country:US
Mailing Address - Phone:310-917-2200
Mailing Address - Fax:310-917-2204
Practice Address - Street 1:1131 WILSHIRE BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2061
Practice Address - Country:US
Practice Address - Phone:310-917-2200
Practice Address - Fax:310-917-2204
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 12003171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC 12003OtherLICENSE