Provider Demographics
NPI:1710324843
Name:KIM, KITAK (LAC)
Entity Type:Individual
Prefix:MR
First Name:KITAK
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:719 S GRAMERCY PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-3166
Mailing Address - Country:US
Mailing Address - Phone:213-703-6939
Mailing Address - Fax:
Practice Address - Street 1:3030 W. OLYMPIC BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-6509
Practice Address - Country:US
Practice Address - Phone:213-703-6939
Practice Address - Fax:213-210-2231
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13583171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist