Provider Demographics
NPI:1659147304
Name:SHIMODA, KIMIKO (DIPL OM, LAC)
Entity Type:Individual
Prefix:
First Name:KIMIKO
Middle Name:
Last Name:SHIMODA
Suffix:
Gender:F
Credentials:DIPL OM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18809 W CATAWBA AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-5895
Mailing Address - Country:US
Mailing Address - Phone:704-912-4691
Mailing Address - Fax:
Practice Address - Street 1:18809 W CATAWBA AVE STE 204
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-5895
Practice Address - Country:US
Practice Address - Phone:704-912-4691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2167171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty