Provider Demographics
NPI:1700800950
Name:SHIN, DONG KIL (LAC)
Entity Type:Individual
Prefix:MR
First Name:DONG
Middle Name:KIL
Last Name:SHIN
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 1:435 ARDEN AVE STE 510
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1137
Mailing Address - Country:US
Mailing Address - Phone:818-240-6163
Mailing Address - Fax:818-240-3735
Practice Address - Street 1:435 ARDEN AVE STE 510
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203
Practice Address - Country:US
Practice Address - Phone:818-240-6163
Practice Address - Fax:818-240-3735
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC4184171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist