Healthcare Provider Details

I. General information

NPI: 1124835152
Provider Name (Legal Business Name): MR. KWANG HYUN JI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 12/13/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 LINCOLN AVE APT 163
CYPRESS CA
90630-2991
US

IV. Provider business mailing address

5201 LINCOLN AVE APT 163
CYPRESS CA
90630-2991
US

V. Phone/Fax

Practice location:
  • Phone: 714-393-2275
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC19785
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: