Provider Demographics
NPI:1659130623
Name:KIRK, CAROLINE (LAC)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:KIRK
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 1:2332 ABBOT KINNEY BLVD UNIT A
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-4727
Mailing Address - Country:US
Mailing Address - Phone:609-320-6262
Mailing Address - Fax:
Practice Address - Street 1:2712 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4706
Practice Address - Country:US
Practice Address - Phone:609-320-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19867171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist