Provider Demographics
NPI:1003574013
Name:KIM, JUNGTAE (DC)
Entity Type:Individual
Prefix:DR
First Name:JUNGTAE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 ARTESIA BLVD APT 207
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-1893
Mailing Address - Country:US
Mailing Address - Phone:206-778-0848
Mailing Address - Fax:
Practice Address - Street 1:4959 PALO VERDE ST STE 100B
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2339
Practice Address - Country:US
Practice Address - Phone:909-626-7100
Practice Address - Fax:909-626-0123
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC36169111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor