Provider Demographics
NPI:1821201815
Name:KIM, YOUNG TAE (LAC)
Entity Type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:TAE
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:DR
Other - First Name:YOUNG
Other - Middle Name:TAE
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:9900 BALBOA BLVD.
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325
Mailing Address - Country:US
Mailing Address - Phone:818-701-7070
Mailing Address - Fax:818-993-9900
Practice Address - Street 1:9900 BALBOA BLVD.
Practice Address - Street 2:SUITE B
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325
Practice Address - Country:US
Practice Address - Phone:818-701-7070
Practice Address - Fax:818-993-9900
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9394171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist