=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306220462
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PU POLLY WANG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2015
-----------------------------------------------------
Last Update Date | 07/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 511 1/2 ELIZABETH AVE
-----------------------------------------------------
City | MONTEREY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91755-1403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-633-0398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6513 WHITTIER BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90022-4622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-888-1122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC11270
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------