Provider Demographics
NPI:1336178839
Name:FONG, RICHARD G (DC, LAC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:G
Last Name:FONG
Suffix:
Gender:M
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1949 HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4989
Mailing Address - Country:US
Mailing Address - Phone:626-799-8855
Mailing Address - Fax:626-799-1099
Practice Address - Street 1:1949 HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4989
Practice Address - Country:US
Practice Address - Phone:626-799-8855
Practice Address - Fax:626-799-1099
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17488111N00000X
CAAC3297171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT18550Medicare UPIN
CADC17488Medicare PIN
CADC17488AMedicare PIN