Provider Demographics
NPI:1558575407
Name:KIM, CHAN HO
Entity Type:Individual
Prefix:MR
First Name:CHAN
Middle Name:HO
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24639 WILLOW TER
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-4570
Mailing Address - Country:US
Mailing Address - Phone:213-268-5337
Mailing Address - Fax:
Practice Address - Street 1:555 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-1612
Practice Address - Country:US
Practice Address - Phone:310-756-0001
Practice Address - Fax:310-756-0004
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7574171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist