Provider Demographics
NPI:1275562985
Name:KIMURA, SHAWN ISAO (DC,LAC)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:ISAO
Last Name:KIMURA
Suffix:
Gender:M
Credentials:DC,LAC
Other - Prefix:
Other - First Name:SHAWN
Other - Middle Name:
Other - Last Name:KIMURA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC, LAC, BS
Mailing Address - Street 1:8121 W. 3RD ST.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4308
Mailing Address - Country:US
Mailing Address - Phone:323-852-1023
Mailing Address - Fax:323-651-1533
Practice Address - Street 1:8121 W. 3RD ST.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4308
Practice Address - Country:US
Practice Address - Phone:323-852-1023
Practice Address - Fax:323-651-1533
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC16449111NS0005X, 111N00000X
CAAC6670171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC6670OtherACUPUNCTURE LICENSE NUMBE
CAAC6670OtherACUPUNCTURE LICENSE NUMBE
CADC16449Medicare UPIN