Provider Demographics
NPI:1073948188
Name:KIM, JAY
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14511 FRANKLIN AVE # 260
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7203
Mailing Address - Country:US
Mailing Address - Phone:714-512-7336
Mailing Address - Fax:949-857-2228
Practice Address - Street 1:14511 FRANKLIN AVE # 260
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7203
Practice Address - Country:US
Practice Address - Phone:714-512-7336
Practice Address - Fax:949-857-2228
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7955171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist