Provider Demographics
NPI:1619610672
Name:KIM, LYDIA (LAC)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:5311 FRANCIS LEWIS BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 NORTHER BLVD. STE. 406
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021
Practice Address - Country:US
Practice Address - Phone:516-209-0788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007035-01229N00000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No229N00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersAnaplastologist