Healthcare Provider Details

I. General information

NPI: 1629285671
Provider Name (Legal Business Name): KANDI ANN WONG PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N ELMS RD
FLUSHING MI
48433-9426
US

IV. Provider business mailing address

1163 NORTON ST
BURTON MI
48529-1156
US

V. Phone/Fax

Practice location:
  • Phone: 810-342-5554
  • Fax: 810-342-5589
Mailing address:
  • Phone: 810-342-5554
  • Fax: 810-342-5589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: