=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720214828
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELISA KANANI WONG L. AC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2009
-----------------------------------------------------
Last Update Date | 04/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 923 S CATALINA AVE
-----------------------------------------------------
City | PEDONDO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-540-8333
-----------------------------------------------------
Fax | 310-540-8385
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1203 N FAIRVALE AVE
-----------------------------------------------------
City | COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-290-7999
-----------------------------------------------------
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 | 12981
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------