Provider Demographics
NPI:1639305006
Name:KIM, AUDREY BENA (LAC)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:BENA
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 1:15140 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3343
Mailing Address - Country:US
Mailing Address - Phone:818-386-0983
Mailing Address - Fax:818-386-0984
Practice Address - Street 1:15140 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3343
Practice Address - Country:US
Practice Address - Phone:818-386-0983
Practice Address - Fax:818-386-0984
Is Sole Proprietor?:No
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11914171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist