Provider Demographics
NPI:1558806851
Name:KIM, LYDIA Y (LAC)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:Y
Last Name:KIM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8929 S SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3616
Mailing Address - Country:US
Mailing Address - Phone:213-800-3772
Mailing Address - Fax:310-475-8018
Practice Address - Street 1:8929 S SEPULVEDA BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3616
Practice Address - Country:US
Practice Address - Phone:213-800-3772
Practice Address - Fax:310-475-8018
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17056171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist