Healthcare Provider Details

I. General information

NPI: 1720878382
Provider Name (Legal Business Name): ULTIMATE MALE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 E LAS TUNAS DR STE 204
SAN GABRIEL CA
91776-5514
US

IV. Provider business mailing address

360 E LAS TUNAS DR STE 204
SAN GABRIEL CA
91776-5514
US

V. Phone/Fax

Practice location:
  • Phone: 626-319-5261
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: YUAN WANG
Title or Position: MANAGER
Credential:
Phone: 626-319-5261