Healthcare Provider Details

I. General information

NPI: 1023378908
Provider Name (Legal Business Name): GARY KWO R.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2012
Last Update Date: 05/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6732 136TH ST #B
FLUSHING NY
11367-1624
US

IV. Provider business mailing address

6732 136TH ST #B
FLUSHING NY
11367-1624
US

V. Phone/Fax

Practice location:
  • Phone: 949-395-3038
  • Fax:
Mailing address:
  • Phone: 949-395-3038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1055314
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: