Provider Demographics
NPI:1679723720
Name:KIM, KEVIN HYUNGSUP (DC, LAC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:HYUNGSUP
Last Name:KIM
Suffix:
Gender:M
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10195 MAIN ST STE F
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3415
Mailing Address - Country:US
Mailing Address - Phone:703-277-9897
Mailing Address - Fax:703-277-9535
Practice Address - Street 1:10195 MAIN ST STE F
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3415
Practice Address - Country:US
Practice Address - Phone:703-277-9897
Practice Address - Fax:703-277-9535
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30297111N00000X
VA0104556491111N00000X
VA0121000759171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist