Provider Demographics
NPI:1811736523
Name:VAN, LOAN PHAM (DC)
Entity type:Individual
Prefix:
First Name:LOAN
Middle Name:PHAM
Last Name:VAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 CONRAD LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8532
Mailing Address - Country:US
Mailing Address - Phone:817-368-8138
Mailing Address - Fax:
Practice Address - Street 1:12540 WILLOW SPRINGS RD STE 116
Practice Address - Street 2:
Practice Address - City:HASLET
Practice Address - State:TX
Practice Address - Zip Code:76052-3523
Practice Address - Country:US
Practice Address - Phone:817-381-2207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16057111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor