Provider Demographics
NPI:1609206366
Name:LY CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:LY CHIROPRACTIC, INC
Other - Org Name:VALLEY WELLNESS HEALTH GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TAM
Authorized Official - Middle Name:
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:510-303-0807
Mailing Address - Street 1:4950 HAMILTON AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95130-1748
Mailing Address - Country:US
Mailing Address - Phone:408-256-3865
Mailing Address - Fax:408-550-1974
Practice Address - Street 1:4950 HAMILTON AVE STE 109
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95130-1748
Practice Address - Country:US
Practice Address - Phone:408-256-3865
Practice Address - Fax:408-550-1974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-16
Last Update Date:2019-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29804111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty