Provider Demographics
NPI:1306069109
Name:ATLANTIC HEALTHCARE
Entity type:Organization
Organization Name:ATLANTIC HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:Z
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:L AC
Authorized Official - Phone:626-308-0805
Mailing Address - Street 1:901 E VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3608
Mailing Address - Country:US
Mailing Address - Phone:626-308-0805
Mailing Address - Fax:626-280-1616
Practice Address - Street 1:901 E VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3608
Practice Address - Country:US
Practice Address - Phone:626-308-0805
Practice Address - Fax:626-280-1616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC8801171100000X
CAA72461208D00000X
CAA72461A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA72461AMedicare ID - Type UnspecifiedPHYSICIAN