Provider Demographics
NPI:1104065523
Name:KIM, KELLY EUNJOO (LAC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:EUNJOO
Last Name:KIM
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 1:280 NEWPORT CENTER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7526
Mailing Address - Country:US
Mailing Address - Phone:949-729-9987
Mailing Address - Fax:
Practice Address - Street 1:280 NEWPORT CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7526
Practice Address - Country:US
Practice Address - Phone:949-729-9987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11276171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist