Provider Demographics
NPI:1114813052
Name:WANG, JIAOLUAN
Entity type:Individual
Prefix:
First Name:JIAOLUAN
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12625 FREDERICK ST STE E1
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5253
Mailing Address - Country:US
Mailing Address - Phone:951-542-0722
Mailing Address - Fax:
Practice Address - Street 1:8360 CLOVER CREEK RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-3512
Practice Address - Country:US
Practice Address - Phone:951-542-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47745225700000X
CA0033183443747P1801X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant