Healthcare Provider Details

I. General information

NPI: 1831983360
Provider Name (Legal Business Name): NATHAN WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3532 MONROE ST
RIVERSIDE CA
92504-6322
US

IV. Provider business mailing address

3008 JACQUELINE DR
WEST COVINA CA
91792-2321
US

V. Phone/Fax

Practice location:
  • Phone: 626-888-0567
  • Fax:
Mailing address:
  • Phone: 626-888-0567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: