MEDICARE: DR. SHELLEY S KIM O.D.

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	152W00000X	Optometrist	046-0009187	IL

General Provider Information

NPI Number	:	1396752846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHELLEY S KIM O.D.

Provider Business Mailing Address
First Line	:	1950 OLD GALLOWS RD STE 520
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-3970
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	571-223-6780

Provider Business Practice Location Address
First Line	:	865 ELMHURST RD
Second Line	:
City	:	DES PLAINES
State	:	IL
Zip	:	60016-5605
Country	:	US
Telephone Number	:	847-437-1005
Fax Number	:	847-437-0755

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	11/18/2020

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