Basic Information
| Provider Information | |||||||||
| NPI: | 1750976510 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUN | ||||||||
| FirstName: | BRIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3660 SE 29TH AVE APT 2108 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972022179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2135873085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1720 E CESAR E CHAVEZ AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900332414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232685000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2021 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/01/2022 | ||||||||
| NPIReactivationDate: | 08/01/2022 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.