Provider Demographics
NPI:1831692086
Name:TANUDJAJA, VIVIAN
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:TANUDJAJA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6481 ATLANTIC AVE APT 135
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-2339
Mailing Address - Country:US
Mailing Address - Phone:562-612-5696
Mailing Address - Fax:
Practice Address - Street 1:6481 ATLANTIC AVE APT 135
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-2339
Practice Address - Country:US
Practice Address - Phone:562-612-5696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer