Provider Demographics
NPI:1063997013
Name:KIM, CHONG KOO (ACUPUNCTURIST)
Entity type:Individual
Prefix:MR
First Name:CHONG
Middle Name:KOO
Last Name:KIM
Suffix:
Gender:M
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 HIGHLAND AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1384
Mailing Address - Country:US
Mailing Address - Phone:201-274-3323
Mailing Address - Fax:
Practice Address - Street 1:420 HIGHLAND AVE APT 10
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1384
Practice Address - Country:US
Practice Address - Phone:201-274-3323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5297171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist