Provider Demographics
NPI:1518176684
Name:KIM, SEUNG TAE (LAC)
Entity Type:Individual
Prefix:
First Name:SEUNG
Middle Name:TAE
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 1:2966 WILSHIRE BL.
Mailing Address - Street 2:1ST FL.
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010
Mailing Address - Country:US
Mailing Address - Phone:213-487-3133
Mailing Address - Fax:213-487-3233
Practice Address - Street 1:2966 WILSHIRE BL.
Practice Address - Street 2:1ST FL.
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010
Practice Address - Country:US
Practice Address - Phone:213-487-3133
Practice Address - Fax:213-487-3233
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5596171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC005569Medicaid