Provider Demographics
NPI:1851122907
Name:KIM, BYUNG ROK (MAOM, LAC)
Entity type:Individual
Prefix:
First Name:BYUNG
Middle Name:ROK
Last Name:KIM
Suffix:
Gender:M
Credentials:MAOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33100 PACIFIC HWY S STE 1
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6445
Mailing Address - Country:US
Mailing Address - Phone:253-815-9191
Mailing Address - Fax:
Practice Address - Street 1:33100 PACIFIC HWY S STE 1
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6445
Practice Address - Country:US
Practice Address - Phone:253-815-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC61517510305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization