Healthcare Provider Details

I. General information

NPI: 1760671267
Provider Name (Legal Business Name): DR. NANCY WANG, OD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N EUCLID AVE STE A
UPLAND CA
91786-6031
US

IV. Provider business mailing address

300 N EUCLID AVE STE A
UPLAND CA
91786-6031
US

V. Phone/Fax

Practice location:
  • Phone: 909-982-9002
  • Fax: 909-982-9912
Mailing address:
  • Phone: 909-982-9002
  • Fax: 909-982-9912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number11233T
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number11233T
License Number StateCA

VIII. Authorized Official

Name: DR. NANCY WANG
Title or Position: OWNER
Credential: OD
Phone: 909-982-9002