Provider Demographics
NPI:1821534959
Name:KIM, BAE (L AC)
Entity Type:Individual
Prefix:
First Name:BAE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15500 S NORMANDIE AVE # B
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4014
Mailing Address - Country:US
Mailing Address - Phone:310-650-1303
Mailing Address - Fax:
Practice Address - Street 1:15500 S NORMANDIE AVE # B
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4014
Practice Address - Country:US
Practice Address - Phone:310-650-1303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7073171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist