Provider Demographics
NPI:1609153782
Name:BONG, CHAD ISAAC (LAC, LOM)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:ISAAC
Last Name:BONG
Suffix:
Gender:M
Credentials:LAC, LOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1542
Mailing Address - Country:US
Mailing Address - Phone:267-210-9877
Mailing Address - Fax:
Practice Address - Street 1:1618 SOUTH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1542
Practice Address - Country:US
Practice Address - Phone:267-210-9877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOM000089171100000X
CO1485171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist