Provider Demographics
NPI:1487056651
Name:KIM, JIWONG (LAC)
Entity type:Individual
Prefix:
First Name:JIWONG
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 1:16261 LAGUNA CANYON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3608
Mailing Address - Country:US
Mailing Address - Phone:714-636-3886
Mailing Address - Fax:714-636-3459
Practice Address - Street 1:16261 LAGUNA CANYON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3608
Practice Address - Country:US
Practice Address - Phone:714-636-3886
Practice Address - Fax:714-636-3459
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15744171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC15744OtherCALIFORNIA ACUPUNCTURE BOARD