Healthcare Provider Details

I. General information

NPI: 1275604522
Provider Name (Legal Business Name): KSJ ACUPUNCTURE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12402 INDUSTRIAL BLVD SUITE B2
VICTORVILLE CA
92395-5871
US

IV. Provider business mailing address

2150 CHEYENNE WAY UNIT 177
FULLERTON CA
92833-4949
US

V. Phone/Fax

Practice location:
  • Phone: 760-428-2800
  • Fax:
Mailing address:
  • Phone: 323-821-5522
  • Fax: 714-848-9546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC8143
License Number StateCA

VIII. Authorized Official

Name: DR. SANG JO KIM
Title or Position: OWNER
Credential: L.AC.
Phone: 323-821-5522