Provider Demographics
NPI:1306022975
Name:VAN, MONG (DC)
Entity Type:Individual
Prefix:
First Name:MONG
Middle Name:
Last Name:VAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 WEBSTER ST
Mailing Address - Street 2:UNIT 1
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-2708
Mailing Address - Country:US
Mailing Address - Phone:857-413-0591
Mailing Address - Fax:
Practice Address - Street 1:1798 MASSACHUSETTS AVE # A
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-2860
Practice Address - Country:US
Practice Address - Phone:857-413-0591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9123111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor