Provider Demographics
NPI:1528363363
Name:VAN, PHUNG (DC)
Entity Type:Individual
Prefix:DR
First Name:PHUNG
Middle Name:
Last Name:VAN
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 1:9324 S ROBERTS RD
Mailing Address - Street 2:SUITE 1N
Mailing Address - City:HICKORY HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60457-3800
Mailing Address - Country:US
Mailing Address - Phone:708-598-3429
Mailing Address - Fax:708-575-0891
Practice Address - Street 1:9324 S ROBERTS RD
Practice Address - Street 2:SUITE 1N
Practice Address - City:HICKORY HILLS
Practice Address - State:IL
Practice Address - Zip Code:60457-3800
Practice Address - Country:US
Practice Address - Phone:708-598-3429
Practice Address - Fax:708-575-0891
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011889111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1528363363Medicare PIN