Provider Demographics
NPI:1245773027
Name:KIM, SOOYEOL
Entity Type:Individual
Prefix:
First Name:SOOYEOL
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 1:9327 FAIRWAY VIEW PL STE 204
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0969
Mailing Address - Country:US
Mailing Address - Phone:675-341-2125
Mailing Address - Fax:
Practice Address - Street 1:9327 FAIRWAY VIEW PL STE 204
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0969
Practice Address - Country:US
Practice Address - Phone:675-341-2125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17443171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist