Provider Demographics
NPI:1073960530
Name:KIM, SOO K (LAC)
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:K
Last Name:KIM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 SYLVAN AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-2726
Mailing Address - Country:US
Mailing Address - Phone:646-932-4100
Mailing Address - Fax:
Practice Address - Street 1:385 SYLVAN AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2726
Practice Address - Country:US
Practice Address - Phone:646-932-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-15
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00119200171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist