Provider Demographics
NPI:1902013741
Name:KIM, SANG JO (LAC)
Entity Type:Individual
Prefix:MR
First Name:SANG JO
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 1:2150 CHEYENNE WAY
Mailing Address - Street 2:UNIT 177
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4949
Mailing Address - Country:US
Mailing Address - Phone:760-428-2800
Mailing Address - Fax:
Practice Address - Street 1:12402 INDUSTRIAL BLVD
Practice Address - Street 2:UNIT B2
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5871
Practice Address - Country:US
Practice Address - Phone:760-428-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC8143171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0081430OtherMEDICAL
CA0600841Medicaid