Provider Demographics
NPI:1770926305
Name:KIM, CASEY Y (PHD, LAC)
Entity type:Individual
Prefix:DR
First Name:CASEY
Middle Name:Y
Last Name:KIM
Suffix:
Gender:F
Credentials:PHD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11344 NAPOLI DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-8532
Mailing Address - Country:US
Mailing Address - Phone:909-320-0695
Mailing Address - Fax:
Practice Address - Street 1:1914 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-1537
Practice Address - Country:US
Practice Address - Phone:213-389-8275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-13
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15345171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist