Provider Demographics
NPI:1437467461
Name:PROM, VAN SIENG (DC)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:SIENG
Last Name:PROM
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 1:1031 MCHENRY AVE STE 22
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5434
Mailing Address - Country:US
Mailing Address - Phone:209-527-7766
Mailing Address - Fax:209-529-7766
Practice Address - Street 1:1031 MCHENRY AVE. STE. 22
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-527-7766
Practice Address - Fax:209-529-7766
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21786111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor