1710465372 NPI number — KELLIE-ANNE CHIEMI ISHII-KIM OD

Table of content: KELLIE-ANNE CHIEMI ISHII-KIM OD (NPI 1710465372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710465372 NPI number — KELLIE-ANNE CHIEMI ISHII-KIM OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ISHII-KIM
Provider First Name:
KELLIE-ANNE
Provider Middle Name:
CHIEMI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

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:
1710465372
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3621 WOODPECKER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92823-1064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 W BONITA AVE STE 110B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIMAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91773-2543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-394-0462
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/04/2018

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: 152W00000X , with the licence number:  35068 , 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)





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