Provider Demographics
NPI:1215968706
Name:KIM, MIKE (DC)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3511 W OLYMPIC BLVD
Mailing Address - Street 2:202
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-3563
Mailing Address - Country:US
Mailing Address - Phone:323-732-8343
Mailing Address - Fax:323-732-8344
Practice Address - Street 1:3511 W OLYMPIC BLVD
Practice Address - Street 2:202
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-3563
Practice Address - Country:US
Practice Address - Phone:323-732-8343
Practice Address - Fax:323-732-8344
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACD27462111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15698Medicare ID - Type Unspecified