Provider Demographics
NPI:1689088668
Name:KIM, SEONSOOK
Entity Type:Individual
Prefix:
First Name:SEONSOOK
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 SHAWNEE TRL
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-1519
Mailing Address - Country:US
Mailing Address - Phone:973-896-9601
Mailing Address - Fax:973-729-6515
Practice Address - Street 1:54 SHAWNEE TRL
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1519
Practice Address - Country:US
Practice Address - Phone:973-896-9601
Practice Address - Fax:973-729-6515
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00106900171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist