Provider Demographics
NPI:1821472994
Name:KIM, TAE SU
Entity Type:Individual
Prefix:MR
First Name:TAE SU
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 1:20909 PIONEER BLVD APT 7
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90715-1363
Mailing Address - Country:US
Mailing Address - Phone:714-244-0027
Mailing Address - Fax:
Practice Address - Street 1:2787 E DEL AMO BLVD
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-6005
Practice Address - Country:US
Practice Address - Phone:714-244-0027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10617171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist