Provider Demographics
NPI:1568709020
Name:IM, MYOUNG (LAC)
Entity Type:Individual
Prefix:MR
First Name:MYOUNG
Middle Name:
Last Name:IM
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 1:142 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-1908
Mailing Address - Country:US
Mailing Address - Phone:914-439-3117
Mailing Address - Fax:
Practice Address - Street 1:142 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:HARTSDALE
Practice Address - State:NY
Practice Address - Zip Code:10530-1908
Practice Address - Country:US
Practice Address - Phone:914-439-3117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003445-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist