Provider Demographics
NPI:1073002507
Name:RYU, KITAK
Entity Type:Individual
Prefix:
First Name:KITAK
Middle Name:
Last Name:RYU
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 1:825 RAY AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07657
Mailing Address - Country:US
Mailing Address - Phone:201-615-8242
Mailing Address - Fax:
Practice Address - Street 1:777 AVENUE C
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-2844
Practice Address - Country:US
Practice Address - Phone:201-436-0911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00130100171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty