Basic Information
Provider Information
NPI: 1003146580
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MAN
FirstName: OI WAN
MiddleName: ALIA
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 605 W OLYMPIC BLVD STE 600
Address2: APT/SUITE
City: LOS ANGELES
State: CA
PostalCode: 900151475
CountryCode: US
TelephoneNumber: 6264410411
FaxNumber: 2134897993
Practice Location
Address1: 1665 W ADAMS BLVD
Address2: APT/SUITE
City: LOS ANGELES
State: CA
PostalCode: 900071533
CountryCode: US
TelephoneNumber: 3237313534
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/06/2010
LastUpdateDate: 06/12/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700XLCS 12740CAY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


Home