Provider Demographics
NPI:1437329265
Name:KIM, JUNG YOON LEAH (LAC MSTOM)
Entity Type:Individual
Prefix:MS
First Name:JUNG YOON
Middle Name:LEAH
Last Name:KIM
Suffix:
Gender:F
Credentials:LAC MSTOM
Other - Prefix:MS
Other - First Name:J.
Other - Middle Name:LEAH
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:37 W 20TH ST STE 607
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-3718
Mailing Address - Country:US
Mailing Address - Phone:646-279-8836
Mailing Address - Fax:
Practice Address - Street 1:37 W 20TH ST STE 607
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-3718
Practice Address - Country:US
Practice Address - Phone:646-279-8836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003765171100000X
NY25003765171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty