Provider Demographics
NPI:1225724370
Name:KIM, SE-YOUNG
Entity Type:Individual
Prefix:
First Name:SE-YOUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23331 EL TORO RD STE 107
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4809
Mailing Address - Country:US
Mailing Address - Phone:949-943-6161
Mailing Address - Fax:949-625-7818
Practice Address - Street 1:1600 DOVE ST
Practice Address - Street 2:STE 210
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1417
Practice Address - Country:US
Practice Address - Phone:949-943-6161
Practice Address - Fax:949-635-7818
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC00019702174400000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist