Provider Demographics
NPI:1912516915
Name:KIM, SHUA HEEJOO (LAC)
Entity Type:Individual
Prefix:
First Name:SHUA
Middle Name:HEEJOO
Last Name:KIM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 W 22ND ST APT 5N
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-2451
Mailing Address - Country:US
Mailing Address - Phone:718-869-6542
Mailing Address - Fax:
Practice Address - Street 1:303 5TH AVE RM 1314
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6691
Practice Address - Country:US
Practice Address - Phone:646-545-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006719171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist