Healthcare Provider Details

I. General information

NPI: 1992874424
Provider Name (Legal Business Name): BLONG BLIAXA VANG D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 10/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 DUNLAP ST N STE 302
SAINT PAUL MN
55104-4207
US

IV. Provider business mailing address

393 DUNLAP ST N STE 302
SAINT PAUL MN
55104-4207
US

V. Phone/Fax

Practice location:
  • Phone: 651-210-9657
  • Fax: 651-493-4682
Mailing address:
  • Phone: 651-210-9657
  • Fax: 651-493-4682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number4471
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: