Provider Demographics
NPI:1821264284
Name:KIM, SAM
Entity Type:Individual
Prefix:
First Name:SAM
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 1:6290 ABBOTTS BRIDGE RD STE 203
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1750
Mailing Address - Country:US
Mailing Address - Phone:770-696-4714
Mailing Address - Fax:
Practice Address - Street 1:6290 ABBOTTS BRIDGE RD STE 203
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1750
Practice Address - Country:US
Practice Address - Phone:770-696-4714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA200171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist