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General NPI Number Information
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NPI Number | 1962986042
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Entity Type | Individual
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Provider Name | LONG PHAM
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Gender | Male
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Dates
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Enumeration Date | 09/24/2018
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Last Update Date | 09/24/2018
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Provider Practice Location Address
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Address Line | 7175 ENCLAVE DR
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City | EASTVALE
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State | CA
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Zip | 92880-3828
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Country | US
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Telephone | 318-791-9853
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Fax |
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Provider Business Mailing Address
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Address Line | 7175 ENCLAVE DR
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City | EASTVALE
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State | CA
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Zip | 92880-3828
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Country | US
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Telephone | 318-791-9853
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225800000X
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Taxonomy Name | Recreation Therapist
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License Number | 29433
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License Number State | CA
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