Provider Demographics
NPI:1861887747
Name:KIM, SUNG JIN (DPT)
Entity type:Individual
Prefix:
First Name:SUNG
Middle Name:JIN
Last Name:KIM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:1121 RAVENCREST RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-2953
Mailing Address - Country:US
Mailing Address - Phone:714-356-1049
Mailing Address - Fax:
Practice Address - Street 1:1706 W ORANGETHORPE AVE STE F
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-4556
Practice Address - Country:US
Practice Address - Phone:714-475-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42303225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA42303Medicaid