Provider Demographics
NPI:1427122639
Name:WONG, JOHN W (LAC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
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 1:316 SAN LUIS REY RD
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-3010
Mailing Address - Country:US
Mailing Address - Phone:626-447-7027
Mailing Address - Fax:
Practice Address - Street 1:65 N MADISON AVE
Practice Address - Street 2:#710
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2035
Practice Address - Country:US
Practice Address - Phone:626-844-2998
Practice Address - Fax:626-844-2998
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11256171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC11256OtherSTATE LICENSE