Healthcare Provider Details

I. General information

NPI: 1245589969
Provider Name (Legal Business Name): JUNBOUM KANG MSOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 YGNACIO VALLEY RD. BUILDING E, SUITE 204
WALNUT CREEK CA
94598-3383
US

IV. Provider business mailing address

2121 YGNACIO VALLEY RD. BUILDING E, SUITE 204
WALNUT CREEK CA
94598-3383
US

V. Phone/Fax

Practice location:
  • Phone: 925-280-4599
  • Fax:
Mailing address:
  • Phone: 925-280-4599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC14667
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: