Provider Demographics
NPI:1982831913
Name:HENRY WONG CHIROPRACTIC PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:HENRY WONG CHIROPRACTIC PROFESSIONAL CORPORATION
Other - Org Name:GREATER LIFE FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:619-222-8885
Mailing Address - Street 1:3689 MIDWAY DRIVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5265
Mailing Address - Country:US
Mailing Address - Phone:619-222-8885
Mailing Address - Fax:619-222-8889
Practice Address - Street 1:3689 MIDWAY DRIVE
Practice Address - Street 2:SUITE G
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5265
Practice Address - Country:US
Practice Address - Phone:619-222-8885
Practice Address - Fax:619-222-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-17
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27967111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC27967Medicare UPIN