Provider Demographics
NPI:1699301564
Name:KIM, MIJI (LAC)
Entity type:Individual
Prefix:
First Name:MIJI
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1384 W FOOTHILL BLVD APT 10
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3648
Mailing Address - Country:US
Mailing Address - Phone:909-247-9532
Mailing Address - Fax:
Practice Address - Street 1:12360 PENN ST STE A
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1103
Practice Address - Country:US
Practice Address - Phone:562-789-1588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-22
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18763171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty