Provider Demographics
NPI:1306284328
Name:KIM, WAN (LAC)
Entity type:Individual
Prefix:
First Name:WAN
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 1:100 SARATOGA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-7337
Mailing Address - Country:US
Mailing Address - Phone:408-645-8232
Mailing Address - Fax:408-217-2410
Practice Address - Street 1:100 SARATOGA AVE STE 110
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-7337
Practice Address - Country:US
Practice Address - Phone:408-645-8232
Practice Address - Fax:408-217-2410
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13915171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist