Provider Demographics
NPI:1265812309
Name:KI TAE KIM CHIROPRACTIC INC.
Entity type:Organization
Organization Name:KI TAE KIM CHIROPRACTIC INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KI
Authorized Official - Middle Name:TAE
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:408-829-3019
Mailing Address - Street 1:2211 MOORPARK AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2654
Mailing Address - Country:US
Mailing Address - Phone:408-829-3019
Mailing Address - Fax:888-734-8668
Practice Address - Street 1:2211 MOORPARK AVE
Practice Address - Street 2:SUITE 280
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2654
Practice Address - Country:US
Practice Address - Phone:408-829-3019
Practice Address - Fax:888-734-8668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27786261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service