Provider Demographics
NPI:1336924646
Name:KIM, CHANGBAE (LAC)
Entity Type:Individual
Prefix:MR
First Name:CHANGBAE
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 1:13229 CAROLYN ST
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-8605
Mailing Address - Country:US
Mailing Address - Phone:562-822-8912
Mailing Address - Fax:
Practice Address - Street 1:100 N STATE COLLEGE BLVD STE E
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-4236
Practice Address - Country:US
Practice Address - Phone:562-822-8912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17583171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist