Provider Demographics
NPI:1003133638
Name:KIM, KI S (L, AC)
Entity Type:Individual
Prefix:
First Name:KI
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:L, AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:8202 NE STATE HIGHWAY 104
Mailing Address - Street 2:SUITE 105
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-9454
Mailing Address - Country:US
Mailing Address - Phone:360-297-0037
Mailing Address - Fax:360-267-0420
Practice Address - Street 1:8202 NE STATE HIGHWAY 104
Practice Address - Street 2:SUITE 105
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-9454
Practice Address - Country:US
Practice Address - Phone:360-297-0037
Practice Address - Fax:360-267-0420
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAAC60131515171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist