MEDICARE: HEEBAE KONG L.AC

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	171100000X	Acupuncturist	4278	NY

General Provider Information

NPI Number	:	1861711137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEEBAE KONG L.AC

Provider Business Mailing Address
First Line	:	407 PARK AVE S APT 5B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10016-8415
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	407 PARK AVE S APT 5B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10016-8415
Country	:	US
Telephone Number	:	646-397-3398
Fax Number	:

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

Provider Enumeration Date	:	05/25/2010
Last Update Date	:	05/25/2010

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Directions to “ HEEBAE KONG L.AC” Practice Location

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