Provider Demographics
NPI:1194848507
Name:KIM, JI SUNG (LAC)
Entity Type:Individual
Prefix:
First Name:JI SUNG
Middle Name:
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 1:402 S MARGINAL RD
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-1913
Mailing Address - Country:US
Mailing Address - Phone:917-698-0025
Mailing Address - Fax:
Practice Address - Street 1:402 S MARGINAL RD
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-1913
Practice Address - Country:US
Practice Address - Phone:917-698-0025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003161171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist