Provider Demographics
NPI:1679850226
Name:KIM, KELLY HYUN SOOK (LAC)
Entity Type:Individual
Prefix:
First Name:KELLY HYUN SOOK
Middle Name:
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 1:1410 ENCINO AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-4310
Mailing Address - Country:US
Mailing Address - Phone:213-408-1422
Mailing Address - Fax:
Practice Address - Street 1:899 W FOOTHILL BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-1973
Practice Address - Country:US
Practice Address - Phone:213-408-1422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14478171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist