Healthcare Provider Details

I. General information

NPI: 1174047112
Provider Name (Legal Business Name): AI WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 SAINT ALBANS RD
SAN MARINO CA
91108-1864
US

IV. Provider business mailing address

1525 SAINT ALBANS RD
SAN MARINO CA
91108-1864
US

V. Phone/Fax

Practice location:
  • Phone: 951-367-5640
  • Fax:
Mailing address:
  • Phone: 951-367-5640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: