Healthcare Provider Details

I. General information

NPI: 1659235026
Provider Name (Legal Business Name): YOUNGKI KIM LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 LAVISTA RD NE STE G
ATLANTA GA
30329-3951
US

IV. Provider business mailing address

502 WINSTON CROFT CIR
JOHNS CREEK GA
30022-6718
US

V. Phone/Fax

Practice location:
  • Phone: 770-710-8539
  • Fax: 404-325-9874
Mailing address:
  • Phone: 470-949-1913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number593
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: