Provider Demographics
NPI:1578055653
Name:KIM, SHINWON (LAC)
Entity Type:Individual
Prefix:
First Name:SHINWON
Middle Name:
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 1:4155 MOORPARK AVE
Mailing Address - Street 2:STE 20
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117
Mailing Address - Country:US
Mailing Address - Phone:866-845-9589
Mailing Address - Fax:
Practice Address - Street 1:4155 MOORPARK AVE
Practice Address - Street 2:STE 20
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117
Practice Address - Country:US
Practice Address - Phone:866-845-9589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17555171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist