Provider Demographics
NPI:1205335585
Name:KIM, CAROLINE Y (LAC)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:Y
Last Name:KIM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 NW VICKSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-1435
Mailing Address - Country:US
Mailing Address - Phone:503-343-9848
Mailing Address - Fax:
Practice Address - Street 1:1633 NW VICKSBURG AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-1435
Practice Address - Country:US
Practice Address - Phone:503-343-9848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC180366171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty