=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679723720
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN HYUNGSUP KIM DC, LAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2008
-----------------------------------------------------
Last Update Date | 05/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10195 MAIN ST STE F
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-3415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-277-9897
-----------------------------------------------------
Fax | 703-277-9535
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10195 MAIN ST STE F
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-3415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-277-9897
-----------------------------------------------------
Fax | 703-277-9535
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC30297
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0104556491
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 0121000759
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------