Provider Demographics
NPI:1245383876
Name:WANG, PHILIP (LAC)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:WANG
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 1:901 E VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3608
Mailing Address - Country:US
Mailing Address - Phone:626-308-0805
Mailing Address - Fax:626-308-0805
Practice Address - Street 1:901 E VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3608
Practice Address - Country:US
Practice Address - Phone:626-308-0805
Practice Address - Fax:626-308-0805
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC8801171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist