Provider Demographics
NPI:1659746451
Name:SEO, KANG
Entity Type:Individual
Prefix:
First Name:KANG
Middle Name:
Last Name:SEO
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 1:111 W OLD COUNTRY RD
Mailing Address - Street 2:SUITE 001
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-4036
Mailing Address - Country:US
Mailing Address - Phone:516-433-4570
Mailing Address - Fax:516-433-4578
Practice Address - Street 1:111 W OLD COUNTRY RD
Practice Address - Street 2:SUITE 001
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-4036
Practice Address - Country:US
Practice Address - Phone:516-433-4570
Practice Address - Fax:516-433-4578
Is Sole Proprietor?:No
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039791225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist