Provider Demographics
NPI:1639488133
Name:KIM, YOUNG WAN (ACUPUNCTURIST)
Entity Type:Individual
Prefix:
First Name:YOUNG
Middle Name:WAN
Last Name:KIM
Suffix:
Gender:M
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 HENRIETTA AVE
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1913
Mailing Address - Country:US
Mailing Address - Phone:818-489-0460
Mailing Address - Fax:
Practice Address - Street 1:3120 HENRIETTA AVE
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-1913
Practice Address - Country:US
Practice Address - Phone:818-489-0460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13588171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist