Provider Demographics
NPI:1053628727
Name:LA, NINA HONG QUYEN (DC, LAC)
Entity Type:Individual
Prefix:DR
First Name:NINA HONG QUYEN
Middle Name:
Last Name:LA
Suffix:
Gender:F
Credentials:DC, LAC
Other - Prefix:DR
Other - First Name:NINA
Other - Middle Name:
Other - Last Name:LA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC, LAC
Mailing Address - Street 1:17122 BEACH BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-5992
Mailing Address - Country:US
Mailing Address - Phone:714-681-2811
Mailing Address - Fax:855-260-8190
Practice Address - Street 1:17122 BEACH BLVD STE 100
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5992
Practice Address - Country:US
Practice Address - Phone:714-681-2811
Practice Address - Fax:855-260-8190
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31581111N00000X
CA13214171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADY495AOtherMEDICARE PTAN