Provider Demographics
NPI:1376058545
Name:KIM, VISMAY HYOUNGWAN (LAC)
Entity Type:Individual
Prefix:
First Name:VISMAY
Middle Name:HYOUNGWAN
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 1:8384 SIX FORKS RD STE 203
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-5089
Mailing Address - Country:US
Mailing Address - Phone:919-397-0943
Mailing Address - Fax:
Practice Address - Street 1:8384 SIX FORKS RD STE 203
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5089
Practice Address - Country:US
Practice Address - Phone:919-397-0943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAC-974171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist