Provider Demographics
NPI:1366104028
Name:LUONG, KHANH (AS PT (PTA))
Entity type:Individual
Prefix:
First Name:KHANH
Middle Name:
Last Name:LUONG
Suffix:
Gender:M
Credentials:AS PT (PTA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 LELAND ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-3118
Mailing Address - Country:US
Mailing Address - Phone:909-222-2851
Mailing Address - Fax:
Practice Address - Street 1:1560 LELAND ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-3118
Practice Address - Country:US
Practice Address - Phone:909-222-2851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant