Provider Demographics
NPI:1962583633
Name:KIM, CHA MI (L AC)
Entity type:Individual
Prefix:DR
First Name:CHA
Middle Name:MI
Last Name:KIM
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6230 BRANDY PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-3896
Mailing Address - Country:US
Mailing Address - Phone:909-944-8054
Mailing Address - Fax:
Practice Address - Street 1:13801 ROSWELL AVE
Practice Address - Street 2:SUITE G
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-5466
Practice Address - Country:US
Practice Address - Phone:909-548-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 9447171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist