Provider Demographics
NPI:1194296509
Name:CHAN, IAN LEI (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:MISS
First Name:IAN LEI
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:DOROTHY
Other - Middle Name:IAN
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:621 PASQUAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91775-2121
Mailing Address - Country:US
Mailing Address - Phone:310-948-9383
Mailing Address - Fax:
Practice Address - Street 1:801 W VALLEY BLVD STE 206
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-3257
Practice Address - Country:US
Practice Address - Phone:626-283-5128
Practice Address - Fax:888-851-3688
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered