Provider Demographics
NPI:1881180354
Name:KIM, DAVID (LAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21441 42ND AVE STE 4C
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2963
Mailing Address - Country:US
Mailing Address - Phone:212-470-0612
Mailing Address - Fax:
Practice Address - Street 1:21441 42ND AVE STE 4C
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2963
Practice Address - Country:US
Practice Address - Phone:212-470-0612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-07
Last Update Date:2018-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6190171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist