Healthcare Provider Details

I. General information

NPI: 1518284496
Provider Name (Legal Business Name): KYLE C WUNG PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2010
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 SAN GABRIEL BLVD SUITE 200
ROSEMEAD CA
91770-5204
US

IV. Provider business mailing address

2630 SAN GABRIEL BLVD SUITE 200
ROSEMEAD CA
91770-5204
US

V. Phone/Fax

Practice location:
  • Phone: 626-280-9968
  • Fax: 877-400-0565
Mailing address:
  • Phone: 626-280-9968
  • Fax: 877-400-0565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 29620
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC13693
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: