Provider Demographics
NPI:1851919864
Name:NA, KYOUNG JOO
Entity Type:Individual
Prefix:
First Name:KYOUNG
Middle Name:JOO
Last Name:NA
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 1:910 S GRAMERCY PL APT 107
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-2193
Mailing Address - Country:US
Mailing Address - Phone:602-882-8606
Mailing Address - Fax:
Practice Address - Street 1:3460 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-2124
Practice Address - Country:US
Practice Address - Phone:323-733-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18300171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty