Provider Demographics
NPI:1700259785
Name:KIM, JI YOUNG (ACUPUNCTURIST)
Entity Type:Individual
Prefix:
First Name:JI YOUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192-15A 64TH CIR. #1A
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365
Mailing Address - Country:US
Mailing Address - Phone:917-476-7981
Mailing Address - Fax:
Practice Address - Street 1:192-15A 64TH CIR. #1A
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365
Practice Address - Country:US
Practice Address - Phone:917-476-7981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002860171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist