Provider Demographics
NPI:1255755690
Name:KWAK, JUNGGYU
Entity type:Individual
Prefix:
First Name:JUNGGYU
Middle Name:
Last Name:KWAK
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 1:290 S LEMON ST #400
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805
Mailing Address - Country:US
Mailing Address - Phone:714-980-0514
Mailing Address - Fax:
Practice Address - Street 1:7800 COMMONWEALTH AVE #203
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621
Practice Address - Country:US
Practice Address - Phone:714-670-9138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 15423171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist