MEDICARE: MR. BON WOOK KOO LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC5582	CA

General Provider Information

NPI Number	:	1831308881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BON WOOK KOO LAC

Provider Business Mailing Address
First Line	:	2833 W 8TH ST STE 101
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90005-1289
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2833 W 8TH ST STE 101
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90005-1289
Country	:	US
Telephone Number	:	213-427-1299
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/08/2007

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