Healthcare Provider Details

I. General information

NPI: 1356957054
Provider Name (Legal Business Name): ALEX VINCENT PHAM DC, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3523 SE 176TH AVE
VANCOUVER WA
98683-3591
US

IV. Provider business mailing address

3523 SE 176TH AVE
VANCOUVER WA
98683-3591
US

V. Phone/Fax

Practice location:
  • Phone: 360-690-6479
  • Fax:
Mailing address:
  • Phone: 360-690-6479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number61483660
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number61483558
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: