Healthcare Provider Details

I. General information

NPI: 1437458908
Provider Name (Legal Business Name): WON KYUNG KEUM C.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 03/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 PARK AVE
PLAINFIELD NJ
07060-1203
US

IV. Provider business mailing address

77 LIBERTY ST UNIT 28
LITTLE FERRY NJ
07643-1763
US

V. Phone/Fax

Practice location:
  • Phone: 732-718-9530
  • Fax:
Mailing address:
  • Phone: 732-718-9530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00045400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number002765
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAK000790
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: