Provider Demographics
NPI:1134373152
Name:WONG, MAN MAN (LAC)
Entity type:Individual
Prefix:
First Name:MAN
Middle Name:MAN
Last Name:WONG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 W VALLEY BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-2479
Mailing Address - Country:US
Mailing Address - Phone:626-282-7527
Mailing Address - Fax:
Practice Address - Street 1:1108 W VALLEY BLVD STE 5
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-2479
Practice Address - Country:US
Practice Address - Phone:626-282-7527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC1591171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist