Healthcare Provider Details

I. General information

NPI: 1306524749
Provider Name (Legal Business Name): BRIAN WANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 W BURBANK BLVD STE B
BURBANK CA
91505-2200
US

IV. Provider business mailing address

15110 TAMARACK CT
NORTH HILLS CA
91343-7823
US

V. Phone/Fax

Practice location:
  • Phone: 818-638-9586
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: