Provider Demographics
NPI:1306199161
Name:JEONG, KWANGRANG (ACUPUNCTURIST)
Entity Type:Individual
Prefix:MR
First Name:KWANGRANG
Middle Name:
Last Name:JEONG
Suffix:
Gender:M
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 FRANCIS LEWIS BLVD
Mailing Address - Street 2:1L
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3042
Mailing Address - Country:US
Mailing Address - Phone:718-225-6889
Mailing Address - Fax:
Practice Address - Street 1:4505 FRANCIS LEWIS BLVD
Practice Address - Street 2:1L
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3042
Practice Address - Country:US
Practice Address - Phone:718-225-6889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4730-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist