Provider Demographics
NPI:1841478252
Name:KONG, STACI MARIE (DC)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:MARIE
Last Name:KONG
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:PO BOX 5603
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93031-5603
Mailing Address - Country:US
Mailing Address - Phone:805-487-4043
Mailing Address - Fax:805-487-4003
Practice Address - Street 1:300 S MCLEAN BLVD STE N
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-1023
Practice Address - Country:US
Practice Address - Phone:847-697-1234
Practice Address - Fax:847-697-8205
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0383011104111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor