Provider Demographics
NPI:1578641023
Name:KIM, JI YONG (LAC)
Entity Type:Individual
Prefix:DR
First Name:JI
Middle Name:YONG
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 1:225 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1588
Mailing Address - Country:US
Mailing Address - Phone:201-363-0233
Mailing Address - Fax:201-363-0244
Practice Address - Street 1:225 BROAD AVE
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1588
Practice Address - Country:US
Practice Address - Phone:201-363-0233
Practice Address - Fax:201-363-0244
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00045000171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist