Provider Demographics
NPI:1093001794
Name:KIM, GINA (LAC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 W. COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833
Mailing Address - Country:US
Mailing Address - Phone:714-676-5828
Mailing Address - Fax:174-676-5829
Practice Address - Street 1:1841 W COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-3013
Practice Address - Country:US
Practice Address - Phone:714-676-5828
Practice Address - Fax:174-676-5829
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13799171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist