Basic Information
| Provider Information | |||||||||
| NPI: | 1508257106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | LAURA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 524 SOUTHPARK BLVD | ||||||||
| Address2: | JENCARE NEIGHBORHOOD MEDICAL SOUTH PARK, LLC | ||||||||
| City: | COLONIAL HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238343609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045047980 | ||||||||
| FaxNumber: | 8045047991 | ||||||||
| Practice Location | |||||||||
| Address1: | 524 SOUTHPARK BLVD | ||||||||
| Address2: | JENCARE NEIGHBORHOOD MEDICAL SOUTH PARK, LLC | ||||||||
| City: | COLONIAL HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238343609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045047980 | ||||||||
| FaxNumber: | 8045047991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2015 | ||||||||
| LastUpdateDate: | 02/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | 0121000697 | VA | Y | Other Service Providers | Acupuncturist |
No ID Information.