Provider Demographics
NPI:1790525400
Name:PHAM, LONG (LAC)
Entity type:Individual
Prefix:
First Name:LONG
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 CAMP RD # 91
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4012
Mailing Address - Country:US
Mailing Address - Phone:843-580-3391
Mailing Address - Fax:
Practice Address - Street 1:2033 LANNEAU LN
Practice Address - Street 2:
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455-8276
Practice Address - Country:US
Practice Address - Phone:843-580-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMAP418171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist