Provider Demographics
NPI:1629130281
Name:KIM, JAE SEOB (LAC)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:SEOB
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 1:773 EL PASO AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-3806
Mailing Address - Country:US
Mailing Address - Phone:213-700-9497
Mailing Address - Fax:
Practice Address - Street 1:773 EL PASO AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-3806
Practice Address - Country:US
Practice Address - Phone:213-700-9497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10811171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC10811OtherCA LICENSED ACUPUNCTURIST