Provider Demographics
NPI:1164585840
Name:KIM, DANIEL BOUM (LAC PHD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:BOUM
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 C ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-5122
Mailing Address - Country:US
Mailing Address - Phone:510-889-8062
Mailing Address - Fax:510-537-6380
Practice Address - Street 1:917 C ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-5122
Practice Address - Country:US
Practice Address - Phone:510-889-8062
Practice Address - Fax:510-537-6380
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC2498171100000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7590612Medicaid