Provider Demographics
NPI:1275817744
Name:TERRY WONG D C LLC
Entity Type:Organization
Organization Name:TERRY WONG D C LLC
Other - Org Name:TERRY WONG D C LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:702-871-5556
Mailing Address - Street 1:3300 S DECATUR BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-8147
Mailing Address - Country:US
Mailing Address - Phone:702-871-5556
Mailing Address - Fax:702-871-5594
Practice Address - Street 1:3300 S DECATUR BLVD STE 5
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-8147
Practice Address - Country:US
Practice Address - Phone:702-871-5556
Practice Address - Fax:702-871-5594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB00691111N00000X
CA19363111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV31533Medicare PIN