Provider Demographics
NPI:1740599141
Name:KIM, DIANA MI (LIC AC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MI
Last Name:KIM
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9027 FREMONT CT
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92344-9240
Mailing Address - Country:US
Mailing Address - Phone:760-628-4777
Mailing Address - Fax:760-949-2534
Practice Address - Street 1:15885 MAIN ST
Practice Address - Street 2:SUITE 280
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-3452
Practice Address - Country:US
Practice Address - Phone:760-628-4777
Practice Address - Fax:760-949-2534
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-02
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13352171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist