Provider Demographics
NPI:1386162576
Name:YIM, NYEONJAE (LAC)
Entity type:Individual
Prefix:
First Name:NYEONJAE
Middle Name:
Last Name:YIM
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 1:6301 BEACH BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-4030
Mailing Address - Country:US
Mailing Address - Phone:714-522-2100
Mailing Address - Fax:714-783-0935
Practice Address - Street 1:6301 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2840
Practice Address - Country:US
Practice Address - Phone:714-522-2100
Practice Address - Fax:714-783-0935
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16298171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist