Provider Demographics
NPI:1174151385
Name:LAN, ALVIN J
Entity type:Individual
Prefix:
First Name:ALVIN
Middle Name:J
Last Name:LAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 STRASSNER DR UNIT 3307
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1887
Mailing Address - Country:US
Mailing Address - Phone:314-662-6505
Mailing Address - Fax:
Practice Address - Street 1:120 ELZORA ST
Practice Address - Street 2:
Practice Address - City:MILTON FREEWATER
Practice Address - State:OR
Practice Address - Zip Code:97862-9454
Practice Address - Country:US
Practice Address - Phone:469-524-5563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019026215208100000X
ORCP000390T208100000X
OR63890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation