Provider Demographics
NPI:1699898924
Name:KIM, DAE KWON (LAC)
Entity type:Individual
Prefix:
First Name:DAE KWON
Middle Name:
Last Name:KIM
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 1:403 N OAKHURST DR APT 104
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4030
Mailing Address - Country:US
Mailing Address - Phone:213-210-5553
Mailing Address - Fax:310-385-0108
Practice Address - Street 1:403 N OAKHURST DR APT 104
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4030
Practice Address - Country:US
Practice Address - Phone:213-210-5553
Practice Address - Fax:310-385-0108
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC 9710OtherACUPUNCTURE