Provider Demographics
NPI:1942451018
Name:KIM, JEONG.S
Entity Type:Individual
Prefix:
First Name:JEONG.S
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 CLARK DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-5616
Mailing Address - Country:US
Mailing Address - Phone:714-873-7791
Mailing Address - Fax:
Practice Address - Street 1:2236 CLARK DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-5616
Practice Address - Country:US
Practice Address - Phone:714-873-7791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12704171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist