Provider Demographics
NPI:1174734719
Name:KIM, TAE (LAC)
Entity type:Individual
Prefix:
First Name:TAE
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 1:2040 PACIFIC COAST HWY STE Q
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-2660
Mailing Address - Country:US
Mailing Address - Phone:310-891-2235
Mailing Address - Fax:
Practice Address - Street 1:2040 PACIFIC COAST HWY STE Q
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-2660
Practice Address - Country:US
Practice Address - Phone:310-891-2235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 9868171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist