Provider Demographics
NPI:1306187281
Name:WONG, JOHNNY T (LMT)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:T
Last Name:WONG
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2571 W EAU GALLIE BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8302
Mailing Address - Country:US
Mailing Address - Phone:321-806-0203
Mailing Address - Fax:
Practice Address - Street 1:2571 W EAU GALLIE BLVD STE 3
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8302
Practice Address - Country:US
Practice Address - Phone:321-806-0203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-02
Last Update Date:2013-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA67692225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist