Provider Demographics
NPI:1548327935
Name:KIM, CLARK WONG (HYNOTIST)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:WONG
Last Name:KIM
Suffix:
Gender:M
Credentials:HYNOTIST
Other - Prefix:
Other - First Name:NAM
Other - Middle Name:WONG
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1112 W ARIZONA AVE
Mailing Address - Street 2:# E
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-5766
Mailing Address - Country:US
Mailing Address - Phone:928-669-8764
Mailing Address - Fax:909-790-9353
Practice Address - Street 1:1112 W ARIZONA AVE
Practice Address - Street 2:# E
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-5766
Practice Address - Country:US
Practice Address - Phone:928-669-8764
Practice Address - Fax:909-790-9353
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ804-363133N00000X
AZN-609171100000X
COBL-00003-04171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133N00000XDietary & Nutritional Service ProvidersNutritionist
Not Answered171100000XOther Service ProvidersAcupuncturist