MEDICARE: TAE HYUN KIM L.AC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC7730	CA

General Provider Information

NPI Number	:	1255601647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAE HYUN KIM L.AC.

Provider Business Mailing Address
First Line	:	3125 MONTROSE AVE APT 22
Second Line	:
City	:	LA CRESCENTA
State	:	CA
Zip	:	91214-3693
Country	:	US
Telephone Number	:	213-215-2348
Fax Number	:

Provider Business Practice Location Address
First Line	:	9132 SEPULVEDA BLVD # N-19
Second Line	:
City	:	NORTH HILLS
State	:	CA
Zip	:	91343-3921
Country	:	US
Telephone Number	:	213-215-2348
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2012
Last Update Date	:	01/26/2012

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