Provider Demographics
NPI:1659557502
Name:KIM CHIROPRACTIC CLINIC, P.A.
Entity Type:Organization
Organization Name:KIM CHIROPRACTIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUNG
Authorized Official - Middle Name:KWON
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-815-2300
Mailing Address - Street 1:13880 BRADDOCK RD STE 207
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2463
Mailing Address - Country:US
Mailing Address - Phone:703-815-2300
Mailing Address - Fax:703-815-1313
Practice Address - Street 1:13880 BRADDOCK RD STE 207
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2463
Practice Address - Country:US
Practice Address - Phone:703-815-2300
Practice Address - Fax:703-815-1313
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIM CHIROPRACTIC CLINIC, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-10
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555864111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU73589Medicare UPIN