MEDICARE: DR. GRAND GONG ZHAO C.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC6291	CA

General Provider Information

NPI Number	:	1104935337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRAND GONG ZHAO C.A.

Provider Business Mailing Address
First Line	:	1729 E PORTNER ST
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91791-3545
Country	:	US
Telephone Number	:	626-512-6075
Fax Number	:

Provider Business Practice Location Address
First Line	:	18938 LABIN CT STE A205-2
Second Line	:
City	:	ROWLAND HEIGHTS
State	:	CA
Zip	:	91748-2285
Country	:	US
Telephone Number	:	626-512-6075
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	09/12/2015

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