Provider Demographics
NPI:1720237142
Name:KONG, BYUNGSUK ALEX (LAC)
Entity Type:Individual
Prefix:MR
First Name:BYUNGSUK
Middle Name:ALEX
Last Name:KONG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 S FULLER AVE
Mailing Address - Street 2:#11A
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-5552
Mailing Address - Country:US
Mailing Address - Phone:213-344-7546
Mailing Address - Fax:
Practice Address - Street 1:350 S FULLER AVE
Practice Address - Street 2:#11A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-5552
Practice Address - Country:US
Practice Address - Phone:213-344-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12585171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12585OtherCALIFORNIA ACUPUNCTURE BOARD