Provider Demographics
NPI:1447557574
Name:WONG, KIN KONG (LAC)
Entity Type:Individual
Prefix:
First Name:KIN
Middle Name:KONG
Last Name:WONG
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:PO BOX 520391
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11352-0391
Mailing Address - Country:US
Mailing Address - Phone:718-886-8180
Mailing Address - Fax:
Practice Address - Street 1:33 WALT WHITMAN RD STE 100A
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-3631
Practice Address - Country:US
Practice Address - Phone:631-271-3310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004386171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY022262OtherMASSAGE LICENSE