Provider Demographics
NPI:1144876624
Name:KIM, MYUNG K (LAC)
Entity type:Individual
Prefix:
First Name:MYUNG
Middle Name:K
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 1:196 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-3324
Mailing Address - Country:US
Mailing Address - Phone:845-501-7878
Mailing Address - Fax:
Practice Address - Street 1:196 MAIN ST
Practice Address - Street 2:
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-3324
Practice Address - Country:US
Practice Address - Phone:845-501-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2020-03-04
Deactivation Date:2019-08-12
Deactivation Code:
Reactivation Date:2019-09-11
Provider Licenses
StateLicense IDTaxonomies
NY005889171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist