Provider Demographics
NPI:1013596642
Name:KIM, JOONGHOON (LAC)
Entity Type:Individual
Prefix:
First Name:JOONGHOON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 WALT WHITMAN RD STE 311
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4112
Mailing Address - Country:US
Mailing Address - Phone:631-923-0334
Mailing Address - Fax:
Practice Address - Street 1:315 WALT WHITMAN RD STE 311
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-4112
Practice Address - Country:US
Practice Address - Phone:631-923-0334
Practice Address - Fax:631-923-0335
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006840171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty