=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699103176
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | K CHIROPRACTIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2013
-----------------------------------------------------
Last Update Date | 10/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15015 41ST AVE STE 3
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-4929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-321-8522
-----------------------------------------------------
Fax | 718-321-8524
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15015 41ST AVE STE 3
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-4929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-321-8522
-----------------------------------------------------
Fax | 718-321-8524
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HOSEOK KWAK
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 718-321-8222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 70012029
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------