Healthcare Provider Details

I. General information

NPI: 1164787628
Provider Name (Legal Business Name): SELENA CONSTANCE WONG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SELENA CONSTANCE CHU OD

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 W FOOTHILL BLVD
MONROVIA CA
91016-1938
US

IV. Provider business mailing address

14726 RAMONA AVE STE 203
CHINO CA
91710-5730
US

V. Phone/Fax

Practice location:
  • Phone: 626-358-1080
  • Fax: 626-358-0548
Mailing address:
  • Phone: 626-305-9100
  • Fax: 626-305-0152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG002662
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number33549
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: