Healthcare Provider Details

I. General information

NPI: 1225724370
Provider Name (Legal Business Name): SE-YOUNG KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 DOVE ST STE 210
NEWPORT BEACH CA
92660-1417
US

IV. Provider business mailing address

23331 EL TORO RD STE 107
LAKE FOREST CA
92630-4809
US

V. Phone/Fax

Practice location:
  • Phone: 949-943-6161
  • Fax: 949-635-7818
Mailing address:
  • Phone: 949-943-6161
  • Fax: 949-625-7818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00019702
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberAC00019702
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: