Provider Demographics
NPI:1497177844
Name:MYDOUANGCHANH, EDDY
Entity Type:Individual
Prefix:
First Name:EDDY
Middle Name:
Last Name:MYDOUANGCHANH
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 1:550 S EREMLAND DR
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3100
Mailing Address - Country:US
Mailing Address - Phone:626-332-7829
Mailing Address - Fax:626-332-7829
Practice Address - Street 1:550 S EREMLAND DR
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3100
Practice Address - Country:US
Practice Address - Phone:626-332-7829
Practice Address - Fax:626-332-7829
Is Sole Proprietor?:No
Enumeration Date:2014-01-18
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5542111N00000X
CA34895111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor