Provider Demographics
NPI:1255601647
Name:KIM, TAE HYUN (LAC)
Entity type:Individual
Prefix:
First Name:TAE HYUN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 MONTROSE AVE APT 22
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-3693
Mailing Address - Country:US
Mailing Address - Phone:213-215-2348
Mailing Address - Fax:
Practice Address - Street 1:9132 SEPULVEDA BLVD # N-19
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-3921
Practice Address - Country:US
Practice Address - Phone:213-215-2348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7730171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist