=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013339860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEI LI MD A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2014
-----------------------------------------------------
Last Update Date | 12/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 S GRAND AVE
-----------------------------------------------------
City | GLENDORA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91741-4218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-592-0198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1317 S DIAMOND BAR BLVD UNIT 4007
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91765-5600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-878-6665
-----------------------------------------------------
Fax | 909-595-3705
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MR. ALAN RYONO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-878-6665
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | A105970
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------