Provider Demographics
NPI:1104935337
Name:ZHAO, GRAND GONG (CA)
Entity type:Individual
Prefix:DR
First Name:GRAND
Middle Name:GONG
Last Name:ZHAO
Suffix:
Gender:M
Credentials:CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 E PORTNER ST
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-3545
Mailing Address - Country:US
Mailing Address - Phone:626-512-6075
Mailing Address - Fax:
Practice Address - Street 1:18938 LABIN CT STE A205-2
Practice Address - Street 2:
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748-2285
Practice Address - Country:US
Practice Address - Phone:626-512-6075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2015-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6291171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist