Provider Demographics
NPI:1225538655
Name:KIM, SANGAE (CA)
Entity Type:Individual
Prefix:
First Name:SANGAE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 E FORT UNION BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1531
Mailing Address - Country:US
Mailing Address - Phone:801-900-7733
Mailing Address - Fax:
Practice Address - Street 1:75 E FORT UNION BLVD STE 150
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1531
Practice Address - Country:US
Practice Address - Phone:801-900-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12976993-1201171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty