Healthcare Provider Details

I. General information

NPI: 1992173306
Provider Name (Legal Business Name): MICHELLE WONG X
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 VENICE BLVD STE 109B
CULVER CITY CA
90232-3346
US

IV. Provider business mailing address

3520 WHITE HOUSE PL
LOS ANGELES CA
90004-5908
US

V. Phone/Fax

Practice location:
  • Phone: 310-914-9700
  • Fax:
Mailing address:
  • Phone: 909-912-9808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number15993
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: