1952304016 NPI number — DR. TONY KYUNGSOO KIM D.C.

Table of content: DR. TONY KYUNGSOO KIM D.C. (NPI 1952304016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952304016 NPI number — DR. TONY KYUNGSOO KIM D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
TONY
Provider Middle Name:
KYUNGSOO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952304016
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24318 HEMLOCK AVE
Provider Second Line Business Mailing Address:
E5
Provider Business Mailing Address City Name:
MORENO VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92557-7222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-485-1918
Provider Business Mailing Address Fax Number:
951-346-5600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 MARKET ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CHARLESTOWN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47111-9535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-244-9859
Provider Business Practice Location Address Fax Number:
770-573-9513
Provider Enumeration Date:
05/23/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC27102 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 08002884A . This is a "INDIANA LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".