Provider Demographics
NPI:1134634603
Name:KANG, KWANGYO
Entity Type:Individual
Prefix:
First Name:KWANGYO
Middle Name:
Last Name:KANG
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 1:25301 CABOT RD STE 111
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5511
Mailing Address - Country:US
Mailing Address - Phone:949-691-9795
Mailing Address - Fax:949-763-3070
Practice Address - Street 1:25301 CABOT RD STE 111
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5511
Practice Address - Country:US
Practice Address - Phone:949-691-9795
Practice Address - Fax:949-763-3070
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT292759225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist