Provider Demographics
NPI:1245539758
Name:KIM, JI SUN (LAC)
Entity type:Individual
Prefix:
First Name:JI SUN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:JISUN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CMT
Mailing Address - Street 1:1825 HAMNER AVE STE R
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-2974
Mailing Address - Country:US
Mailing Address - Phone:951-582-9700
Mailing Address - Fax:951-582-9733
Practice Address - Street 1:1825 HAMNER AVE STE R
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-2974
Practice Address - Country:US
Practice Address - Phone:951-582-9700
Practice Address - Fax:951-582-9733
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-23
Last Update Date:2017-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12159171100000X
CA66733225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist