Provider Demographics
NPI:1821309212
Name:NGUYEN, LAC DINH (DC)
Entity Type:Individual
Prefix:DR
First Name:LAC
Middle Name:DINH
Last Name:NGUYEN
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 1:1100 WASHINGTON AVE
Mailing Address - Street 2:LOT C , UNIT C-2
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-3802
Mailing Address - Country:US
Mailing Address - Phone:215-468-7256
Mailing Address - Fax:215-468-7192
Practice Address - Street 1:1100 WASHINGTON AVE
Practice Address - Street 2:LOT C , UNIT C-2
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-3802
Practice Address - Country:US
Practice Address - Phone:215-468-7256
Practice Address - Fax:215-468-7192
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007840L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU82573Medicare UPIN