=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144653064
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANGBUMN KIM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2013
-----------------------------------------------------
Last Update Date | 08/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 525 W CHESTER PIKE #103A
-----------------------------------------------------
City | HAVERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19083-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-789-3678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 525 W CHESTER PIKE #103A
-----------------------------------------------------
City | HAVERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19083-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-789-3678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AK001084
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 005122
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------