Healthcare Provider Details

I. General information

NPI: 1558996082
Provider Name (Legal Business Name): KARINA WONG CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4095 COUNTY CIRCLE DR
RIVERSIDE CA
92503-3410
US

IV. Provider business mailing address

3745 LEMON AVE
LONG BEACH CA
90807-4115
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: