Provider Demographics
NPI:1336506104
Name:KIM, JIN KOOK (LAC)
Entity Type:Individual
Prefix:MR
First Name:JIN
Middle Name:KOOK
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11442 VIKING AVE
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-1813
Mailing Address - Country:US
Mailing Address - Phone:818-403-4265
Mailing Address - Fax:
Practice Address - Street 1:4940 VAN NUYS BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1700
Practice Address - Country:US
Practice Address - Phone:747-998-5330
Practice Address - Fax:747-998-5318
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16844171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist