Provider Demographics
NPI:1174697643
Name:PHAN, LORENZO TIEN (LAC)
Entity type:Individual
Prefix:
First Name:LORENZO
Middle Name:TIEN
Last Name:PHAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 15TH ST APT 202
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32117-2076
Mailing Address - Country:US
Mailing Address - Phone:386-212-9131
Mailing Address - Fax:
Practice Address - Street 1:725 W GRANADA BLVD UNIT 17
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5107
Practice Address - Country:US
Practice Address - Phone:386-255-6953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC00803171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist