Healthcare Provider Details

I. General information

NPI: 1144423302
Provider Name (Legal Business Name): BARRY HARVEY WONG PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 N FERN ST
ORANGE CA
92867-4061
US

IV. Provider business mailing address

1710 N FERN ST
ORANGE CA
92867-4061
US

V. Phone/Fax

Practice location:
  • Phone: 949-276-1276
  • Fax:
Mailing address:
  • Phone: 949-276-1276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT13997
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT13997
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT13997
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: