Provider Demographics
NPI:1689446411
Name:LY, PHILLIP LOUNG
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:LOUNG
Last Name:LY
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 1:305 S CAMELLIA ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-2549
Mailing Address - Country:US
Mailing Address - Phone:714-287-7898
Mailing Address - Fax:
Practice Address - Street 1:1783 FLIGHT WAY
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92782-1838
Practice Address - Country:US
Practice Address - Phone:949-722-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC36745111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor