Provider Demographics
NPI:1114624137
Name:KWAG, JAEWON
Entity type:Individual
Prefix:MR
First Name:JAEWON
Middle Name:
Last Name:KWAG
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 1:4220 W 3RD ST STE 205
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-3450
Mailing Address - Country:US
Mailing Address - Phone:213-718-2259
Mailing Address - Fax:
Practice Address - Street 1:4220 W 3RD ST STE 205
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-3450
Practice Address - Country:US
Practice Address - Phone:213-718-2259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC19641171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist