Provider Demographics
NPI:1780013888
Name:KIM, SUN SOO (LAC)
Entity Type:Individual
Prefix:
First Name:SUN SOO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5250 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029
Mailing Address - Country:US
Mailing Address - Phone:213-392-3949
Mailing Address - Fax:
Practice Address - Street 1:5250 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029
Practice Address - Country:US
Practice Address - Phone:213-392-3949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2015-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10707171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist