Provider Demographics
NPI:1710167630
Name:KIM, RICHARD J (LAC, CA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:J
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC, CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1577 CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-4602
Mailing Address - Country:US
Mailing Address - Phone:646-441-1910
Mailing Address - Fax:201-585-5046
Practice Address - Street 1:1577 CENTER AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-4602
Practice Address - Country:US
Practice Address - Phone:646-441-1910
Practice Address - Fax:201-585-5046
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00049900171100000X
NY0029831171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist