Provider Demographics
NPI:1336506104
Name:KIM, JIN KOOK (LAC)
Entity type:Individual
Prefix:MR
First Name:JIN
Middle Name:KOOK
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:12047 RICASOLI WAY
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-4626
Mailing Address - Country:US
Mailing Address - Phone:818-403-4265
Mailing Address - Fax:
Practice Address - Street 1:18915 NORDHOFF ST STE 6
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-3791
Practice Address - Country:US
Practice Address - Phone:747-998-5330
Practice Address - Fax:747-998-5318
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16844171100000X
CAAC16844171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist