Provider Demographics
NPI:1538395850
Name:KANG, BONGKYUN
Entity type:Individual
Prefix:
First Name:BONGKYUN
Middle Name:
Last Name:KANG
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 1:12555 W. NATIONAL AVE.
Mailing Address - Street 2:#200
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12555 W NATIONAL AVE
Practice Address - Street 2:#200
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4061
Practice Address - Country:US
Practice Address - Phone:262-754-8040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI624-055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist