=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922337997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INFINITY BODY DREAM WORKS INC DBA INFINITY HEALING CTR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2009
-----------------------------------------------------
Last Update Date | 12/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 416 W LAS TUNAS DR STE 201
-----------------------------------------------------
City | SAN GABRIEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91776-1236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-289-8598
-----------------------------------------------------
Fax | 626-289-8278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 416 W LAS TUNAS DR STE 201
-----------------------------------------------------
City | SAN GABRIEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91776-1236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-289-8598
-----------------------------------------------------
Fax | 626-289-8278
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT AND CEO
-----------------------------------------------------
Name | MR. KYLE WONG
-----------------------------------------------------
Credential | LAC
-----------------------------------------------------
Telephone | 626-289-8598
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------