Healthcare Provider Details

I. General information

NPI: 1932627478
Provider Name (Legal Business Name): WILLY HUANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2017
Last Update Date: 09/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 E 120TH ST
LOS ANGELES CA
90059-3052
US

IV. Provider business mailing address

313 S BROADWAY # B
REDONDO BEACH CA
90277-3710
US

V. Phone/Fax

Practice location:
  • Phone: 424-338-2436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number61181
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: