Provider Demographics
NPI:1447337639
Name:LE, STACIE PHUONG (DC)
Entity type:Individual
Prefix:DR
First Name:STACIE
Middle Name:PHUONG
Last Name:LE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12302 GARDEN GROVE BLVD
Mailing Address - Street 2:SUITE #21
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1835
Mailing Address - Country:US
Mailing Address - Phone:714-590-0024
Mailing Address - Fax:714-590-0084
Practice Address - Street 1:12302 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE #21
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1835
Practice Address - Country:US
Practice Address - Phone:714-590-0024
Practice Address - Fax:714-590-0084
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26889111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5761533Medicaid
CAU80648Medicare UPIN