=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386049286
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IN HO KIM L.AC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2014
-----------------------------------------------------
Last Update Date | 04/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4678 HANFORD ST
-----------------------------------------------------
City | DOUGLASTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11362-1032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-203-0072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4678 HANFORD ST
-----------------------------------------------------
City | DOUGLASTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11362-1032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-203-0072
-----------------------------------------------------
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 | 004881-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------