Provider Demographics
NPI:1174885057
Name:KO, JIN WOOK (LAC)
Entity type:Individual
Prefix:
First Name:JIN WOOK
Middle Name:
Last Name:KO
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 1:440 SHATTO PL #419
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1793
Mailing Address - Country:US
Mailing Address - Phone:213-382-2030
Mailing Address - Fax:877-234-2675
Practice Address - Street 1:440 SHATTO PL #419
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1793
Practice Address - Country:US
Practice Address - Phone:213-382-2030
Practice Address - Fax:877-234-2675
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14589171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC14589OtherACUPUNCTURE