Healthcare Provider Details

I. General information

NPI: 1073002507
Provider Name (Legal Business Name): KITAK RYU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 AVENUE C
BAYONNE NJ
07002-2844
US

IV. Provider business mailing address

825 RAY AVE
RIDGEFIELD NJ
07657
US

V. Phone/Fax

Practice location:
  • Phone: 201-436-0911
  • Fax:
Mailing address:
  • Phone: 201-615-8242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00130100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: