Provider Demographics
NPI:1922165257
Name:MICHAEL WONG PT A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL WONG PT A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:626-660-6080
Mailing Address - Street 1:206 E LAS TUNAS DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1411
Mailing Address - Country:US
Mailing Address - Phone:626-660-6080
Mailing Address - Fax:
Practice Address - Street 1:206 E LAS TUNAS DR
Practice Address - Street 2:SUITE 5
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1411
Practice Address - Country:US
Practice Address - Phone:626-660-6080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20628225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17969Medicare PIN