Provider Demographics
NPI:1669848750
Name:GIM, SOOYEON (DC)
Entity Type:Individual
Prefix:
First Name:SOOYEON
Middle Name:
Last Name:GIM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20019 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3018
Mailing Address - Country:US
Mailing Address - Phone:347-653-2497
Mailing Address - Fax:
Practice Address - Street 1:20019 46TH AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3018
Practice Address - Country:US
Practice Address - Phone:347-653-2497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY70 012702111N00000X
NY006634171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist