Provider Demographics
NPI:1396803243
Name:KIM, YOUNG DAE (L AC)
Entity type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:DAE
Last Name:KIM
Suffix:
Gender:M
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1460 E HOLT AVE
Mailing Address - Street 2:SUITE 72
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5856
Mailing Address - Country:US
Mailing Address - Phone:909-623-0302
Mailing Address - Fax:909-623-0480
Practice Address - Street 1:1460 E HOLT AVE
Practice Address - Street 2:SUITE 72
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5856
Practice Address - Country:US
Practice Address - Phone:909-623-0302
Practice Address - Fax:909-623-0480
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 5732171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist