Healthcare Provider Details

I. General information

NPI: 1629466040
Provider Name (Legal Business Name): ROOT ACUPUNCTURE CLINIC. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3180 WILLOW LN STE 118
THOUSAND OAKS CA
91361-4986
US

IV. Provider business mailing address

3180 WILLOW LN STE 118
THOUSAND OAKS CA
91361-4986
US

V. Phone/Fax

Practice location:
  • Phone: 805-379-4747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC13899
License Number StateCA

VIII. Authorized Official

Name: KANG KYUM KIM
Title or Position: ACUPUNCTURIST
Credential:
Phone: 805-379-4747