Provider Demographics
NPI:1417029570
Name:WONG, GREGORY HENRY (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:HENRY
Last Name:WONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5122 KATELLA AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2826
Mailing Address - Country:US
Mailing Address - Phone:562-596-4800
Mailing Address - Fax:562-596-4855
Practice Address - Street 1:5122 KATELLA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2826
Practice Address - Country:US
Practice Address - Phone:562-596-4800
Practice Address - Fax:562-596-4855
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21568111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU38346Medicare UPIN
CADC21568Medicare ID - Type Unspecified