Provider Demographics
NPI:1518070408
Name:WAN, CLIFTON KAMTONG (DC)
Entity Type:Individual
Prefix:
First Name:CLIFTON
Middle Name:KAMTONG
Last Name:WAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:CLIFTON
Other - Middle Name:K
Other - Last Name:WAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 884
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77497-0884
Mailing Address - Country:US
Mailing Address - Phone:281-933-6677
Mailing Address - Fax:281-933-6689
Practice Address - Street 1:11957 BISSONNET ST
Practice Address - Street 2:SUITE C-6
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77099-1425
Practice Address - Country:US
Practice Address - Phone:281-933-6677
Practice Address - Fax:281-933-6689
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5125111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX760310283OtherEIN