Provider Demographics
NPI:1134589534
Name:WONG, GREG
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-5622
Mailing Address - Country:US
Mailing Address - Phone:323-233-0425
Mailing Address - Fax:323-232-2366
Practice Address - Street 1:3800 S FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-1206
Practice Address - Country:US
Practice Address - Phone:323-233-0425
Practice Address - Fax:323-232-2366
Is Sole Proprietor?:No
Enumeration Date:2016-02-26
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Yes172V00000XOther Service ProvidersCommunity Health Worker