Healthcare Provider Details

I. General information

NPI: 1821661315
Provider Name (Legal Business Name): LISA WONG DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 07/21/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 W 8TH ST
LOS ANGELES CA
90017-4420
US

IV. Provider business mailing address

8459 MISSION DR
ROSEMEAD CA
91770-1165
US

V. Phone/Fax

Practice location:
  • Phone: 213-401-1970
  • Fax:
Mailing address:
  • Phone: 626-551-8230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number300402
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: