=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497185482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUNNY G WONG DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2013
-----------------------------------------------------
Last Update Date | 07/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1081 NATHAN DEAN BYP
-----------------------------------------------------
City | ROCKMART
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30153-2011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-757-1899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1081 NATHAN DEAN BYP
-----------------------------------------------------
City | ROCKMART
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30153-2011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-757-1899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------