Healthcare Provider Details

I. General information

NPI: 1376788851
Provider Name (Legal Business Name): STACEY ANGELA WONG M.S., L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 12/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 MCCONNELL AVE
LOS ANGELES CA
90066-7026
US

IV. Provider business mailing address

5300 MCCONNELL AVE
LOS ANGELES CA
90066-7026
US

V. Phone/Fax

Practice location:
  • Phone: 310-482-5668
  • Fax: 310-571-3213
Mailing address:
  • Phone: 310-482-5668
  • Fax: 310-571-3213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 12551
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number99334
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: