MEDICARE: CK PLASTIC SURGERY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1215392055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CK PLASTIC SURGERY INC

Provider Business Mailing Address
First Line	:	2970 W OLYMPIC BLVD
Second Line	:	SUITE 204 & 205
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2518
Country	:	US
Telephone Number	:	213-382-4900
Fax Number	:	213-382-4909

Provider Business Practice Location Address
First Line	:	2970 W OLYMPIC BLVD
Second Line	:	SUITE 204 & 205
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2518
Country	:	US
Telephone Number	:	213-382-4900
Fax Number	:	213-382-4909

Authorized Official
Title or Position	:	CEO
Name	:	DR. KYOUNG KIM
Credential	:	M.D.
Telephone Number	:	213-382-4900

Provider Enumeration Date	:	12/21/2015
Last Update Date	:	12/22/2015

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