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General NPI Number Information
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NPI Number | 1063646727
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Entity Type | Organization
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Legal Business Name | GREENLIFE WELLNESS
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Dates
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Enumeration Date | 05/11/2009
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Last Update Date | 05/11/2009
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Provider Practice Location Address
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Address Line | 18340 COLIMA RD STE 2D
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City | ROWLAND HEIGHTS
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State | CA
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Zip | 91748-2785
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Country | US
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Telephone | 626-297-2340
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Fax |
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Provider Business Mailing Address
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Address Line | 18340 COLIMA RD STE 2D
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City | ROWLAND HEIGHTS
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State | CA
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Zip | 91748-2785
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | DR. DERRICK TANG
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Credential | D.C.
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Telephone | 626-297-2340
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | 27175
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | 27175
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 111NX0800X
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Taxonomy Name | Orthopedic Chiropractor
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License Number | 27175
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License Number State | CA
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