Basic Information
| Provider Information | |||||||||
| NPI: | 1104573336 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | KIM | ||||||||
| FirstName: | KIMIN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5105 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049155100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192205255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 910 W WILLIAMS ST | ||||||||
| Address2: | |||||||||
| City: | APEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275025201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193631957 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2022 | ||||||||
| LastUpdateDate: | 03/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | P20268 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P20268 | 01 | NC | MEDICAL LICENSE | OTHER |