Provider Demographics
NPI:1881415164
Name:PHAM, KHOA DANG (LMT)
Entity type:Individual
Prefix:
First Name:KHOA
Middle Name:DANG
Last Name:PHAM
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:MR
Other - First Name:KHOA
Other - Middle Name:DANG
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:6652 W HAMILTON DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80227-5336
Mailing Address - Country:US
Mailing Address - Phone:512-903-8882
Mailing Address - Fax:
Practice Address - Street 1:1650 38TH ST STE 100E
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2624
Practice Address - Country:US
Practice Address - Phone:720-213-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0023938225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist