Provider Demographics
NPI:1861814121
Name:LIM, COLIN
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:LIM
Suffix:
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 1:483 N AVIATION BLVD BLDG 286
Mailing Address - Street 2:SBD3-CDG
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-2808
Mailing Address - Country:US
Mailing Address - Phone:310-653-6771
Mailing Address - Fax:
Practice Address - Street 1:483 N AVIATION BLVD BLDG 286
Practice Address - Street 2:SBD3-CDG
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-2808
Practice Address - Country:US
Practice Address - Phone:310-653-6771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-06
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1053191041C0700X
AK1315301041C0700X
AK138806225700000X
TXMT119534225700000X
MI7501000163225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX422779ZP3FMedicare PIN