Provider Demographics
NPI:1902416399
Name:KIM, RYON (LAC)
Entity Type:Individual
Prefix:
First Name:RYON
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 1:6428 SCHUBERT CIR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-3126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 YORBA ST STE 100
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2960
Practice Address - Country:US
Practice Address - Phone:714-743-6570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18897171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist