Provider Demographics
NPI:1508257106
Name:WONG, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 SOUTHPARK BLVD
Mailing Address - Street 2:JENCARE NEIGHBORHOOD MEDICAL SOUTH PARK, LLC
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-3609
Mailing Address - Country:US
Mailing Address - Phone:804-504-7980
Mailing Address - Fax:804-504-7991
Practice Address - Street 1:524 SOUTHPARK BLVD
Practice Address - Street 2:JENCARE NEIGHBORHOOD MEDICAL SOUTH PARK, LLC
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-3609
Practice Address - Country:US
Practice Address - Phone:804-504-7980
Practice Address - Fax:804-504-7991
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000697171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist