Provider Demographics
NPI:1902242258
Name:KIM, CHANG SUNG (DC)
Entity Type:Individual
Prefix:DR
First Name:CHANG
Middle Name:SUNG
Last Name:KIM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2391 BELL BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2019
Mailing Address - Country:US
Mailing Address - Phone:718-224-8382
Mailing Address - Fax:718-224-2844
Practice Address - Street 1:2391 BELL BLVD STE 205
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-2019
Practice Address - Country:US
Practice Address - Phone:718-224-8382
Practice Address - Fax:718-224-2844
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012364111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor