Provider Demographics
NPI:1447476064
Name:THE INDUSTRIAL CLINIC AT MONTCLAIR, A MED CORP
Entity type:Organization
Organization Name:THE INDUSTRIAL CLINIC AT MONTCLAIR, A MED CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:X
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-289-9004
Mailing Address - Street 1:55 S RAYMOND AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-7100
Mailing Address - Country:US
Mailing Address - Phone:626-289-9004
Mailing Address - Fax:
Practice Address - Street 1:18575 GALE AVE STE 198
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91748-1382
Practice Address - Country:US
Practice Address - Phone:626-289-9004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32175207X00000X
CAA69486208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty