Provider Demographics
NPI:1336308451
Name:KIM, JUSTIN JUNGCHUL (LAC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JUNGCHUL
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15132 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4313
Mailing Address - Country:US
Mailing Address - Phone:310-850-0931
Mailing Address - Fax:
Practice Address - Street 1:15132 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-4313
Practice Address - Country:US
Practice Address - Phone:310-850-0931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12406171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist