Provider Demographics
NPI:1699952051
Name:KIM, RICHARD (LAC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
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 1:1600 W DEMPSTER ST
Mailing Address - Street 2:204
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1109
Mailing Address - Country:US
Mailing Address - Phone:224-938-9521
Mailing Address - Fax:224-938-9522
Practice Address - Street 1:1600 W DEMPSTER ST STE 206
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1172
Practice Address - Country:US
Practice Address - Phone:224-938-9521
Practice Address - Fax:224-938-9522
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 11999171100000X
IL198.000803171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001Medicaid
IL2778778900Medicare NSC
IL001Medicaid
IL21Medicare UPIN
IL12Medicare PIN