Provider Demographics
NPI:1366687212
Name:KO, SAMUEL JINWOOK (LIC, AC)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:JINWOOK
Last Name:KO
Suffix:
Gender:M
Credentials:LIC, AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18173 PIONEER BLVD STE N
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-3991
Mailing Address - Country:US
Mailing Address - Phone:562-673-8397
Mailing Address - Fax:
Practice Address - Street 1:18173 PIONEER BLVD STE N
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-3991
Practice Address - Country:US
Practice Address - Phone:562-673-8397
Practice Address - Fax:562-591-5295
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-06
Last Update Date:2008-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 6364171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist