Provider Demographics
NPI:1407136419
Name:LEE KIM, MONICA JUNG (LAC DAOM)
Entity Type:Individual
Prefix:MS
First Name:MONICA
Middle Name:JUNG
Last Name:LEE KIM
Suffix:
Gender:F
Credentials:LAC DAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 OCEAN PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-4902
Mailing Address - Country:US
Mailing Address - Phone:310-396-8085
Mailing Address - Fax:
Practice Address - Street 1:1712 OCEAN PARK BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-4902
Practice Address - Country:US
Practice Address - Phone:310-396-8085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4116171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist