MEDICARE: GLORIA WONG

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	251E00000X	Home Health Agency		MN

General Provider Information

NPI Number	:	1366825440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORIA WONG

Provider Business Mailing Address
First Line	:	1321 PAYNE AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55130-3433
Country	:	US
Telephone Number	:	651-771-2420
Fax Number	:	651-771-2421

Provider Business Practice Location Address
First Line	:	1321 PAYNE AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55130-3433
Country	:	US
Telephone Number	:	651-771-2420
Fax Number	:	651-771-2421

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

Provider Enumeration Date	:	07/07/2015
Last Update Date	:	07/07/2015

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