Provider Demographics
NPI:1093990764
Name:KIM, ELLIOT HEEJAE (ACUPUNCTURE)
Entity Type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:HEEJAE
Last Name:KIM
Suffix:
Gender:M
Credentials:ACUPUNCTURE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8253 SIERRA AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3577
Mailing Address - Country:US
Mailing Address - Phone:909-320-2844
Mailing Address - Fax:909-357-1244
Practice Address - Street 1:8253 SIERRA AVE STE 205
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3577
Practice Address - Country:US
Practice Address - Phone:909-320-2844
Practice Address - Fax:909-357-1244
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12044171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12044OtherAC