Provider Demographics
NPI:1346627742
Name:KIM, MICHAEL (LAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:22337 65TH AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22337 65TH AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364-2313
Practice Address - Country:US
Practice Address - Phone:631-375-0306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5537171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist