Provider Demographics
NPI:1851505838
Name:FONG, LAWRENCE (DC)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:FONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20265 VENTURA BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-2550
Mailing Address - Country:US
Mailing Address - Phone:818-669-8669
Mailing Address - Fax:
Practice Address - Street 1:20265 VENTURA BLVD STE C
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2550
Practice Address - Country:US
Practice Address - Phone:818-669-8669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27062111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC27062Medicare ID - Type Unspecified