Provider Demographics
NPI:1861930646
Name:KIM, KEVIN (DPT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-1043
Mailing Address - Country:US
Mailing Address - Phone:562-408-1140
Mailing Address - Fax:562-408-1141
Practice Address - Street 1:4115 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1043
Practice Address - Country:US
Practice Address - Phone:562-408-1140
Practice Address - Fax:562-408-1141
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT291906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist