Provider Demographics
NPI:1376833608
Name:WANG, BOB
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:
Last Name:WANG
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 1:1136 S VALENCIA ST
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-4934
Mailing Address - Country:US
Mailing Address - Phone:626-500-8639
Mailing Address - Fax:
Practice Address - Street 1:630 MISSION ST
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3058
Practice Address - Country:US
Practice Address - Phone:626-799-9888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 14145171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist