MEDICARE: KIL BOO BARK 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	AC 4974	CA

General Provider Information

NPI Number	:	1174735773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIL BOO BARK LAC

Provider Business Mailing Address
First Line	:	2227 JAMES M WOOD BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2105
Country	:	US
Telephone Number	:	213-388-4352
Fax Number	:

Provider Business Practice Location Address
First Line	:	2227 JAMES M WOOD BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2105
Country	:	US
Telephone Number	:	213-388-4352
Fax Number	:

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

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	07/10/2008

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Directions to “ KIL BOO BARK LAC” Practice Location

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