Healthcare Provider Details

I. General information

NPI: 1114813052
Provider Name (Legal Business Name): JIAOLUAN WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8360 CLOVER CREEK RD
RIVERSIDE CA
92508-3512
US

IV. Provider business mailing address

12625 FREDERICK ST STE E1
MORENO VALLEY CA
92553-5253
US

V. Phone/Fax

Practice location:
  • Phone: 951-542-0722
  • Fax:
Mailing address:
  • Phone: 951-542-0722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number47745
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number003318344
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number003318344
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: