Provider Demographics
NPI:1992173306
Name:WONG, MICHELLE X
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WONG
Suffix:X
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 WHITE HOUSE PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-5908
Mailing Address - Country:US
Mailing Address - Phone:909-912-9808
Mailing Address - Fax:
Practice Address - Street 1:10200 VENICE BLVD
Practice Address - Street 2:STE 109B
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3346
Practice Address - Country:US
Practice Address - Phone:310-914-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15993171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist