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General NPI Number Information
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NPI Number | 1528292745
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Entity Type | Organization
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Legal Business Name | KO'S WELLNESS INC.
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Dates
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Enumeration Date | 05/04/2009
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Last Update Date | 05/04/2009
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Provider Practice Location Address
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Address Line | 1931 N GAFFEY ST SUITE C
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City | SAN PEDRO
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State | CA
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Zip | 90731-1265
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Country | US
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Telephone | 310-832-1424
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Fax | 310-832-1424
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Provider Business Mailing Address
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Address Line | 1931 N GAFFEY ST SUITE C
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City | SAN PEDRO
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State | CA
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Zip | 90731-1265
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Country | US
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Telephone | 310-832-1424
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Fax | 310-832-1424
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Authorized Official
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Title or Position | PRESIDENT
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Name | SYNGWAN KO
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Credential | L.AC.
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Telephone | 310-832-1424
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 6239
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License Number State | CA
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