Provider Demographics
NPI:1598164709
Name:KIM, CHUNG EUN
Entity Type:Individual
Prefix:
First Name:CHUNG EUN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 AMES AVE
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-4134
Mailing Address - Country:US
Mailing Address - Phone:650-815-9037
Mailing Address - Fax:
Practice Address - Street 1:1340 S DE ANZA BLVD
Practice Address - Street 2:#104
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-4644
Practice Address - Country:US
Practice Address - Phone:408-622-9386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 15776171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist