Provider Demographics
NPI:1225459472
Name:KIM, SUNG SOO (LAC)
Entity Type:Individual
Prefix:
First Name:SUNG SOO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:SUNG SOO
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:24101 HOLLYOAK APT C
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-7904
Mailing Address - Country:US
Mailing Address - Phone:949-615-9117
Mailing Address - Fax:
Practice Address - Street 1:1101 DOVE ST STE 270
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2819
Practice Address - Country:US
Practice Address - Phone:714-200-6050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-13
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU 490171100000X
CAAC15575171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist