Healthcare Provider Details

I. General information

NPI: 1053568782
Provider Name (Legal Business Name): DAESONG YIM PH.D., LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 AIRPORT WAY # A
FAIRBANKS AK
99701-4002
US

IV. Provider business mailing address

1500 AIRPORT WAY # C
FAIRBANKS AK
99701-4002
US

V. Phone/Fax

Practice location:
  • Phone: 907-456-2100
  • Fax: 907-456-2472
Mailing address:
  • Phone: 907-456-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00003084
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number117
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: