Provider Demographics
NPI:1518284496
Name:WUNG, KYLE C (PT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:C
Last Name:WUNG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 SAN GABRIEL BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-5204
Mailing Address - Country:US
Mailing Address - Phone:626-280-9968
Mailing Address - Fax:877-400-0565
Practice Address - Street 1:2630 SAN GABRIEL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-5204
Practice Address - Country:US
Practice Address - Phone:626-280-9968
Practice Address - Fax:877-400-0565
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-30
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 29620225100000X
CAAC13693171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD7389128OtherCA DRIVER'S LICENSE
CAPT 29620OtherCA PHYSICAL THERAPY BOARD
CAAC13693OtherCA ACUPUNCTURE BOARD
CADG742ZMedicare PIN