=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639346638
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN WONG P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2008
-----------------------------------------------------
Last Update Date | 12/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 GELLERT BLVD SUITE # 222
-----------------------------------------------------
City | DALY CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94015-2621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-307-9422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 172 12TH AVE
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94118-1111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-307-9422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 33023
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------