Provider Demographics
NPI:1144664905
Name:KIM, SONJONG (LAC MSTOM)
Entity type:Individual
Prefix:MR
First Name:SONJONG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38-30 150TH STREET
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354
Mailing Address - Country:US
Mailing Address - Phone:718-744-4333
Mailing Address - Fax:
Practice Address - Street 1:3830 150TH ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4928
Practice Address - Country:US
Practice Address - Phone:718-744-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY003506171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist