Provider Demographics
NPI:1679194567
Name:KIM, SEONGJO
Entity Type:Individual
Prefix:
First Name:SEONGJO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12362 BEACH BLVD STE 10
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-3944
Mailing Address - Country:US
Mailing Address - Phone:714-248-9500
Mailing Address - Fax:714-622-4943
Practice Address - Street 1:12362 BEACH BLVD STE 10
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-3944
Practice Address - Country:US
Practice Address - Phone:714-248-9500
Practice Address - Fax:714-622-4943
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18840171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist