Provider Demographics
NPI:1770724536
Name:KO, KI WAN (LAC)
Entity type:Individual
Prefix:
First Name:KI
Middle Name:WAN
Last Name:KO
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 1:1730 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-1019
Mailing Address - Country:US
Mailing Address - Phone:213-384-1100
Mailing Address - Fax:213-384-1101
Practice Address - Street 1:1730 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-1019
Practice Address - Country:US
Practice Address - Phone:213-384-1100
Practice Address - Fax:213-384-1101
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12839171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AC12839OtherCALIFORNIA ACUPUNCTURE BOARD