=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649448325
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYUNG D. RYU M.S., L.AC.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2008
-----------------------------------------------------
Last Update Date | 05/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1787 MIDDLE COUNTRY RD
-----------------------------------------------------
City | CENTEREACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11720-3507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-321-3090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14725 SANFORD AVE APT 3H
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11355-1212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-321-3090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 003662
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------