Provider Demographics
NPI:1578650867
Name:WONG, TERRY L (DC)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
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 1:2950 S RAINBOW BLVD
Mailing Address - Street 2:STE 250
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-6231
Mailing Address - Country:US
Mailing Address - Phone:702-871-5556
Mailing Address - Fax:702-871-5594
Practice Address - Street 1:2950 S RAINBOW BLVD
Practice Address - Street 2:STE 250
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6231
Practice Address - Country:US
Practice Address - Phone:702-871-5556
Practice Address - Fax:702-871-5594
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB00691111N00000X
CA19363111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
31533Medicare ID - Type Unspecified