Healthcare Provider Details

I. General information

NPI: 1790922391
Provider Name (Legal Business Name): DR KIM CHIROPRACTIC A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2009
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 S WESTLAKE BLVD STE 200
WESTLAKE VILLAGE CA
91362-3885
US

IV. Provider business mailing address

650 S WESTLAKE BLVD STE 200
WESTLAKE VILLAGE CA
91362-3885
US

V. Phone/Fax

Practice location:
  • Phone: 805-777-8154
  • Fax: 805-777-8157
Mailing address:
  • Phone: 805-777-8154
  • Fax: 805-777-8157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC22741
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC12636
License Number StateCA

VIII. Authorized Official

Name: KAP R KIM
Title or Position: PRESIDENT
Credential: D.C., LA.C
Phone: 805-777-8154