Provider Demographics
NPI:1134454267
Name:KWON, MIN KYEONG (LAC)
Entity type:Individual
Prefix:
First Name:MIN
Middle Name:KYEONG
Last Name:KWON
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 1:940 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5331
Mailing Address - Country:US
Mailing Address - Phone:805-925-2395
Mailing Address - Fax:805-666-2724
Practice Address - Street 1:940 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5331
Practice Address - Country:US
Practice Address - Phone:805-779-1255
Practice Address - Fax:805-666-2724
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-07
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10356171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC10356OtherACUPUNCTURE