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General NPI Number Information
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NPI Number | 1720878382
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Entity Type | Organization
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Legal Business Name | ULTIMATE MALE
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Dates
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Enumeration Date | 05/07/2025
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Last Update Date | 05/08/2025
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Provider Practice Location Address
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Address Line | 360 E LAS TUNAS DR STE 204
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City | SAN GABRIEL
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State | CA
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Zip | 91776-5514
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Country | US
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Telephone | 626-319-5261
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Fax |
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Provider Business Mailing Address
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Address Line | 360 E LAS TUNAS DR STE 204
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City | SAN GABRIEL
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State | CA
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Zip | 91776-5514
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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 | MANAGER
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Name | YUAN WANG
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Credential |
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Telephone | 626-319-5261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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