=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215618897
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYUNG JOON KIM DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2023
-----------------------------------------------------
Last Update Date | 06/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4312 54TH ST
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-4639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-777-0754
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4312 54TH ST
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-4639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-777-0754
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X013726-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------