Provider Demographics
NPI:1942761747
Name:KIM, DAEHWAN (L,AC)
Entity Type:Individual
Prefix:
First Name:DAEHWAN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:L,AC
Other - Prefix:
Other - First Name:DANIEL
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:L,AC
Mailing Address - Street 1:9531 SLATER AVE APT 17
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4651
Mailing Address - Country:US
Mailing Address - Phone:213-471-5294
Mailing Address - Fax:
Practice Address - Street 1:421 N BROOKHURST ST STE 124
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-5618
Practice Address - Country:US
Practice Address - Phone:213-471-5294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18276171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty