Provider Demographics
NPI:1831640929
Name:LANG, PHALLY
Entity type:Individual
Prefix:
First Name:PHALLY
Middle Name:
Last Name:LANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 EDGEWOOD AVE S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-5333
Mailing Address - Country:US
Mailing Address - Phone:978-495-1461
Mailing Address - Fax:
Practice Address - Street 1:542 EDGEWOOD AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-5333
Practice Address - Country:US
Practice Address - Phone:978-495-1461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care