Provider Demographics
NPI:1457692071
Name:KIM, JAEHEE (L AC)
Entity type:Individual
Prefix:MR
First Name:JAEHEE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 E CLARK AVE
Mailing Address - Street 2:D
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-5105
Mailing Address - Country:US
Mailing Address - Phone:805-938-5577
Mailing Address - Fax:805-938-5667
Practice Address - Street 1:1145 E CLARK AVE
Practice Address - Street 2:D
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-5105
Practice Address - Country:US
Practice Address - Phone:805-938-5577
Practice Address - Fax:805-938-5667
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15138171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist