Provider Demographics
NPI:1174735773
Name:BARK, KIL BOO (LAC)
Entity type:Individual
Prefix:
First Name:KIL
Middle Name:BOO
Last Name:BARK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2227 JAMES M WOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2105
Mailing Address - Country:US
Mailing Address - Phone:213-388-4352
Mailing Address - Fax:
Practice Address - Street 1:2227 JAMES M WOOD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2105
Practice Address - Country:US
Practice Address - Phone:213-388-4352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 4974171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist