Provider Demographics
NPI:1568641199
Name:KIM, CHANG K (LAC, OMD, PH D)
Entity Type:Individual
Prefix:DR
First Name:CHANG
Middle Name:K
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC, OMD, PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 RESERVATION RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-3257
Mailing Address - Country:US
Mailing Address - Phone:831-384-2313
Mailing Address - Fax:831-384-2314
Practice Address - Street 1:326 RESERVATION RD
Practice Address - Street 2:SUITE E
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-3257
Practice Address - Country:US
Practice Address - Phone:831-384-2313
Practice Address - Fax:831-384-2314
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 1513171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC 1513OtherCA MEDICAL LICENSE