Provider Demographics
NPI:1235274135
Name:KIM, AEJA (LAC)
Entity Type:Individual
Prefix:MRS
First Name:AEJA
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 1:4561 BELL BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3354
Mailing Address - Country:US
Mailing Address - Phone:718-316-8663
Mailing Address - Fax:718-819-8177
Practice Address - Street 1:4561 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3354
Practice Address - Country:US
Practice Address - Phone:718-316-8663
Practice Address - Fax:718-819-8177
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002546171100000X
CA7977171100000X
NJ25MZ00045900171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist