Provider Demographics
NPI:1215155759
Name:KIM, JIYEON (LAC)
Entity type:Individual
Prefix:MISS
First Name:JIYEON
Middle Name:
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 1:24244 SYLVAN GLEN RD UNIT F
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4535
Mailing Address - Country:US
Mailing Address - Phone:213-999-3851
Mailing Address - Fax:909-860-5577
Practice Address - Street 1:2160 S WATERMAN AVE STE D
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3746
Practice Address - Country:US
Practice Address - Phone:909-433-9911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 8676171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC 8676OtherACUPUNTURIST