Provider Demographics
NPI:1780963215
Name:THACH, MICHAEL KWAN (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KWAN
Last Name:THACH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22151 CLARENDON ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-6308
Mailing Address - Country:US
Mailing Address - Phone:818-884-4810
Mailing Address - Fax:
Practice Address - Street 1:22151 CLARENDON ST
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-6308
Practice Address - Country:US
Practice Address - Phone:818-884-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-15
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA379802251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic