Healthcare Provider Details

I. General information

NPI: 1215734884
Provider Name (Legal Business Name): ANN KIM LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2025
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 CHRISTOPHER COLUMBUS DR STE 3A
JERSEY CITY NJ
07302-3432
US

IV. Provider business mailing address

51 QUEEN ANNE RD APT 401
BOGOTA NJ
07603-1817
US

V. Phone/Fax

Practice location:
  • Phone: 201-724-3998
  • Fax:
Mailing address:
  • Phone: 678-717-8575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00175500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: