Provider Demographics
NPI:1912927112
Name:WONG, KEVIN (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
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 1:89 MORAGA WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORINDA
Mailing Address - State:CA
Mailing Address - Zip Code:94563-3023
Mailing Address - Country:US
Mailing Address - Phone:925-254-4040
Mailing Address - Fax:925-254-4047
Practice Address - Street 1:89 MORAGA WAY
Practice Address - Street 2:SUITE A
Practice Address - City:ORINDA
Practice Address - State:CA
Practice Address - Zip Code:94563-3023
Practice Address - Country:US
Practice Address - Phone:925-254-4040
Practice Address - Fax:925-254-4047
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 24855111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0248550Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER