1821392507 NPI number — LUONG T. LY MD INC

Table of content: (NPI 1821392507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821392507 NPI number — LUONG T. LY MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUONG T. 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:
1821392507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 788
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HEMET
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92546-0788
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-929-6260
Provider Business Mailing Address Fax Number:
951-765-2855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 N GARFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTEREY PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91754-1202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-573-2222
Provider Business Practice Location Address Fax Number:
626-307-2186
Provider Enumeration Date:
01/10/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LY
Authorized Official First Name:
LUONG
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
626-890-7973

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  A86007 , 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)