Healthcare Provider Details

I. General information

NPI: 1487261004
Provider Name (Legal Business Name): ZONG CHENG VANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 AMERICAN BLVD E STE 1
BLOOMINGTON MN
55425-1230
US

IV. Provider business mailing address

6436 26TH ST N
OAKDALE MN
55128-3506
US

V. Phone/Fax

Practice location:
  • Phone: 952-767-2267
  • Fax:
Mailing address:
  • Phone: 651-500-1892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number106S00000X
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: