Provider Demographics
NPI:1821782962
Name:KANG, ELISHA (RT(R))
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:KANG
Suffix:
Gender:M
Credentials:RT(R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4095 IVY RUN CIR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5370
Mailing Address - Country:US
Mailing Address - Phone:470-774-9764
Mailing Address - Fax:
Practice Address - Street 1:4095 IVY RUN CIR
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5370
Practice Address - Country:US
Practice Address - Phone:470-774-9764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1061513156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist