Healthcare Provider Details

I. General information

NPI: 1962066076
Provider Name (Legal Business Name): KENNY LUONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 07/17/2022
Certification Date: 07/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CROSFIELD AVE
WEST NYACK NY
10994-2226
US

IV. Provider business mailing address

46 CONTINENTAL RD
MORRIS PLAINS NJ
07950-3406
US

V. Phone/Fax

Practice location:
  • Phone: 845-358-2844
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00366800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number007267
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: