Healthcare Provider Details

I. General information

NPI: 1851505838
Provider Name (Legal Business Name): LAWRENCE FONG D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20265 VENTURA BLVD STE C
WOODLAND HILLS CA
91364-2550
US

IV. Provider business mailing address

20265 VENTURA BLVD STE C
WOODLAND HILLS CA
91364-2550
US

V. Phone/Fax

Practice location:
  • Phone: 818-669-8669
  • Fax:
Mailing address:
  • Phone: 818-669-8669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC27062
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: