MEDICARE: MR. KANG HAK KWON CADC-I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	07458-I	NV

General Provider Information

NPI Number	:	1144087404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KANG HAK KWON CADC-I

Provider Business Mailing Address
First Line	:	5374 PINE RANCH ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-1847
Country	:	US
Telephone Number	:	702-595-2633
Fax Number	:

Provider Business Practice Location Address
First Line	:	4011 MCLEOD DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-4305
Country	:	US
Telephone Number	:	702-472-7627
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2024
Last Update Date	:	03/04/2024

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