Provider Demographics
NPI:1417390352
Name:KIM, CHANG KYOUM (LAC)
Entity Type:Individual
Prefix:MR
First Name:CHANG KYOUM
Middle Name:
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 1:3407 W 6TH ST STE 827
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-2558
Mailing Address - Country:US
Mailing Address - Phone:213-598-7460
Mailing Address - Fax:
Practice Address - Street 1:3407 W 6TH ST #827
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020
Practice Address - Country:US
Practice Address - Phone:213-598-7460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14815171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC14815OtherACUPUNCTURIST