Provider Demographics
NPI:1427361617
Name:KELLY WONG DO INC
Entity Type:Organization
Organization Name:KELLY WONG DO INC
Other - Org Name:KELLY WONG D O INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:626-288-3828
Mailing Address - Street 1:500 N GARFIELD AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-1242
Mailing Address - Country:US
Mailing Address - Phone:626-288-3828
Mailing Address - Fax:626-573-8513
Practice Address - Street 1:500 N GARFIELD AVE STE 105
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1242
Practice Address - Country:US
Practice Address - Phone:626-288-3828
Practice Address - Fax:626-573-8513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-16
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10595261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care