Provider Demographics
NPI:1932168655
Name:TAN, DAVE LYNAEUS (PT)
Entity Type:Individual
Prefix:
First Name:DAVE
Middle Name:LYNAEUS
Last Name:TAN
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 1:2120 E COLUNGA ST
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-4577
Mailing Address - Country:US
Mailing Address - Phone:909-370-1175
Mailing Address - Fax:
Practice Address - Street 1:11406 LOMA LINDA DR
Practice Address - Street 2:WEST ENTRANCE
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3711
Practice Address - Country:US
Practice Address - Phone:909-558-6501
Practice Address - Fax:909-558-6002
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT87282251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic