Healthcare Provider Details

I. General information

NPI: 1013632934
Provider Name (Legal Business Name): KYUNGMI MOON SONOGRAPHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

767 ACADEMY DR
SOLANA BEACH CA
92075-2031
US

IV. Provider business mailing address

4929 BROOKBURN DR
SAN DIEGO CA
92130-2779
US

V. Phone/Fax

Practice location:
  • Phone: 858-703-7067
  • Fax:
Mailing address:
  • Phone: 858-775-2428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number250303
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number250303
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: