Provider Demographics
NPI:1326670621
Name:WONG, MARCIAL JOHNNY
Entity Type:Individual
Prefix:
First Name:MARCIAL
Middle Name:JOHNNY
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 TWIN BRANCH LN
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-2828
Mailing Address - Country:US
Mailing Address - Phone:954-593-5798
Mailing Address - Fax:
Practice Address - Street 1:801 S UNIVERSITY DR UNIT 823-B
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-3336
Practice Address - Country:US
Practice Address - Phone:954-593-5798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH13027111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor