Provider Demographics
NPI:1851733141
Name:KONG, KIN W (LAC)
Entity Type:Individual
Prefix:MS
First Name:KIN
Middle Name:W
Last Name:KONG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 150TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1824
Mailing Address - Country:US
Mailing Address - Phone:510-317-1618
Mailing Address - Fax:510-259-9382
Practice Address - Street 1:1618 150TH AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-1824
Practice Address - Country:US
Practice Address - Phone:510-317-1618
Practice Address - Fax:510-259-9382
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11503171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist