Provider Demographics
NPI:1225785173
Name:NAM, NICK KWANGYEON (DC)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:KWANGYEON
Last Name:NAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12349 HERITAGE SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-3851
Mailing Address - Country:US
Mailing Address - Phone:858-869-4397
Mailing Address - Fax:
Practice Address - Street 1:12349 HERITAGE SPRINGS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3851
Practice Address - Country:US
Practice Address - Phone:562-267-9561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34468111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor