Provider Demographics
NPI:1104198050
Name:KIM, CHI YOUNG (LAC,OMD)
Entity Type:Individual
Prefix:DR
First Name:CHI
Middle Name:YOUNG
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC,OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12719 VALLEY VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1944
Mailing Address - Country:US
Mailing Address - Phone:562-407-7433
Mailing Address - Fax:562-407-7436
Practice Address - Street 1:12719 VALLEY VIEW AVE
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1944
Practice Address - Country:US
Practice Address - Phone:562-407-7433
Practice Address - Fax:562-407-7436
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12690171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist