Provider Demographics
NPI:1316387855
Name:WANG, KEVIN (LAC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6428 S CASS AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-3209
Mailing Address - Country:US
Mailing Address - Phone:312-371-2658
Mailing Address - Fax:
Practice Address - Street 1:6428 S CASS AVENUE
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559
Practice Address - Country:US
Practice Address - Phone:312-371-2658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001106171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist