Provider Demographics
NPI:1750623153
Name:CLOSE, KIM (LAC)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:CLOSE
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 1:7524 N ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-1710
Mailing Address - Country:US
Mailing Address - Phone:773-307-9128
Mailing Address - Fax:
Practice Address - Street 1:1840 OAK AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3642
Practice Address - Country:US
Practice Address - Phone:773-307-9128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-23
Last Update Date:2013-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000926171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist