Provider Demographics
NPI:1356363626
Name:LY, SON T (DC)
Entity type:Individual
Prefix:MR
First Name:SON
Middle Name:T
Last Name:LY
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 1:39233 LIBERTY ST STE C
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1501
Mailing Address - Country:US
Mailing Address - Phone:510-796-7000
Mailing Address - Fax:510-796-7022
Practice Address - Street 1:39233 LIBERTY ST STE C
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1501
Practice Address - Country:US
Practice Address - Phone:510-796-7000
Practice Address - Fax:510-796-7022
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0248850Medicare ID - Type UnspecifiedDC
CAU66521Medicare UPIN