MEDICARE: WANDA LUONG B.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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1437345634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA LUONG B.A.

Provider Business Mailing Address
First Line	:	17707 STUDEBAKER RD
Second Line	:
City	:	CERRITOS
State	:	CA
Zip	:	90703-2640
Country	:	US
Telephone Number	:	562-402-0688
Fax Number	:	562-402-3032

Provider Business Practice Location Address
First Line	:	4548 N LAKEWOOD BLVD
Second Line	:	1/4
City	:	LONG BEACH
State	:	CA
Zip	:	90808-1063
Country	:	US
Telephone Number	:	323-842-9655
Fax Number	:

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

Provider Enumeration Date	:	09/20/2007
Last Update Date	:	09/20/2007

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