Healthcare Provider Details

I. General information

NPI: 1366181059
Provider Name (Legal Business Name): KEVIN WONG CNIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MERRICK RD
ROCKVILLE CENTRE NY
11570-4800
US

IV. Provider business mailing address

50 WINTER ST
QUINCY MA
02169-8726
US

V. Phone/Fax

Practice location:
  • Phone: 516-321-2589
  • Fax:
Mailing address:
  • Phone: 178-188-8229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number4964
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: