Provider Demographics
NPI:1548884646
Name:YIM, JOHNNY JR
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:YIM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 FISHCREEK RD APT 107
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-4469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3950 FISHCREEK RD APT 107
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-4469
Practice Address - Country:US
Practice Address - Phone:207-333-9344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program