1164694014 NPI number — CUONG LY MD, INC

Table of content: (NPI 1164694014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164694014 NPI number — CUONG LY MD, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUONG LY MD, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164694014
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23321 EL TORO RD
Provider Second Line Business Mailing Address:
SUITE H
Provider Business Mailing Address City Name:
LAKE FOREST
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92630-4825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-305-2660
Provider Business Mailing Address Fax Number:
949-305-2036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23321 EL TORO RD
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
LAKE FOREST
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92630-4825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-305-2660
Provider Business Practice Location Address Fax Number:
949-305-2036
Provider Enumeration Date:
04/01/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LY
Authorized Official First Name:
CUONG
Authorized Official Middle Name:
PHU
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
714-425-9403

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  A73873 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)