Provider Demographics
NPI:1366845109
Name:KIM, RENEE S (LAC)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:S
Last Name:KIM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8229 BOONE BLVD STE 402
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2623
Mailing Address - Country:US
Mailing Address - Phone:703-356-5764
Mailing Address - Fax:703-448-3436
Practice Address - Street 1:8229 BOONE BLVD STE 402
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2623
Practice Address - Country:US
Practice Address - Phone:703-356-5764
Practice Address - Fax:703-448-3436
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000721171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist