Healthcare Provider Details

I. General information

NPI: 1457601593
Provider Name (Legal Business Name): TAO WANG DPT, L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 WILSON TER
GLENDALE CA
91206-4007
US

IV. Provider business mailing address

305 SAN MARCOS ST UNIT A
SAN GABRIEL CA
91776-4354
US

V. Phone/Fax

Practice location:
  • Phone: 818-409-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number19485
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT39391
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: