MEDICARE: KENNETH BENJAMIN WONG

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1396261343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH BENJAMIN WONG

Provider Business Mailing Address
First Line	:	4911 13TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-3135
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4911 13TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-3135
Country	:	US
Telephone Number	:	718-431-0073
Fax Number	:	718-679-9383

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2017
Last Update Date	:	07/03/2019

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