Provider Demographics
NPI:1407057870
Name:KIM, SHIN JA (DC)
Entity type:Individual
Prefix:DR
First Name:SHIN
Middle Name:JA
Last Name:KIM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3663 W 6TH ST
Mailing Address - Street 2:#201
Mailing Address - City:LA
Mailing Address - State:CA
Mailing Address - Zip Code:90020
Mailing Address - Country:US
Mailing Address - Phone:213-389-0155
Mailing Address - Fax:213-389-2099
Practice Address - Street 1:3663 W 6TH ST
Practice Address - Street 2:#201
Practice Address - City:LA
Practice Address - State:CA
Practice Address - Zip Code:90020
Practice Address - Country:US
Practice Address - Phone:213-389-0155
Practice Address - Fax:213-389-2099
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19869111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6707225Medicaid
CA6707225Medicaid