Provider Demographics
NPI:1629106117
Name:KIM, KI TAE (DC)
Entity Type:Individual
Prefix:DR
First Name:KI
Middle Name:TAE
Last Name:KIM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 N BASCOM AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1866
Mailing Address - Country:US
Mailing Address - Phone:408-975-9606
Mailing Address - Fax:408-975-9616
Practice Address - Street 1:206 N BASCOM AVE STE A
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1866
Practice Address - Country:US
Practice Address - Phone:408-975-9606
Practice Address - Fax:408-975-9616
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27786111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor