Provider Demographics
NPI:1396892766
Name:KANG, PETER JIN SOO (LAC)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:JIN SOO
Last Name:KANG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:MR
Other - First Name:JIN
Other - Middle Name:SOO
Other - Last Name:KANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1820 LENCAR WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-3621
Mailing Address - Country:US
Mailing Address - Phone:408-264-1038
Mailing Address - Fax:
Practice Address - Street 1:1820 LENCAR WAY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-3621
Practice Address - Country:US
Practice Address - Phone:408-264-1038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC202171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist