MEDICARE: PREMIER WOUND CARE OF LOS ANGELES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1366956690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER WOUND CARE OF LOS ANGELES

Provider Business Mailing Address
First Line	:	315 WISTERIA WAY
Second Line	:
City	:	SIERRA MADRE
State	:	CA
Zip	:	91024-1137
Country	:	US
Telephone Number	:	626-679-5118
Fax Number	:

Provider Business Practice Location Address
First Line	:	711 W COLLEGE ST STE 188
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90012-1093
Country	:	US
Telephone Number	:	213-261-0889
Fax Number	:	213-261-0889

Authorized Official
Title or Position	:	CEO, MD
Name	:	SHUO STEVEN WANG
Credential	:	MD
Telephone Number	:	213-261-0889

Provider Enumeration Date	:	11/22/2017
Last Update Date	:	11/22/2017

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