Provider Demographics
NPI:1508909516
Name:TA, DONG QUANG (DC)
Entity Type:Individual
Prefix:
First Name:DONG
Middle Name:QUANG
Last Name:TA
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 1:320 W WALNUT ST APT 51
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-6675
Mailing Address - Country:US
Mailing Address - Phone:909-464-0992
Mailing Address - Fax:909-464-0913
Practice Address - Street 1:2248 S GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-5616
Practice Address - Country:US
Practice Address - Phone:909-464-0992
Practice Address - Fax:909-464-0913
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26659111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0266591Medicaid
CADC26659AMedicare ID - Type Unspecified