Provider Demographics
NPI:1154340206
Name:LY, KHEANG (DC)
Entity type:Individual
Prefix:DR
First Name:KHEANG
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:KRIS
Other - Middle Name:
Other - Last Name:LY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:1004 S OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-2250
Mailing Address - Country:US
Mailing Address - Phone:626-518-2077
Mailing Address - Fax:
Practice Address - Street 1:8977 FOOTHILL BLVD STE D
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3498
Practice Address - Country:US
Practice Address - Phone:909-989-0944
Practice Address - Fax:909-980-9669
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30062111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor