Provider Demographics
NPI:1093326324
Name:HAN, KYUNGMO (PHD, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:KYUNGMO
Middle Name:
Last Name:HAN
Suffix:
Gender:M
Credentials:PHD, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT OF KINESIOLOGY 11811 NORDHOFF STREET
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91330-8287
Mailing Address - Country:US
Mailing Address - Phone:310-951-5827
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF KINESIOLOGY 18111 NORDHOFF STREET
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91330-0001
Practice Address - Country:US
Practice Address - Phone:818-677-5815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty