Healthcare Provider Details

I. General information

NPI: 1114337946
Provider Name (Legal Business Name): RICKY L KUO L.AC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 MISSION BLVD #7
SAN DIEGO CA
92109-2541
US

IV. Provider business mailing address

24111 CINDY LN
LAKE FOREST CA
92630-1814
US

V. Phone/Fax

Practice location:
  • Phone: 858-581-2287
  • Fax:
Mailing address:
  • Phone: 858-367-3752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 15868
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: