Healthcare Provider Details

I. General information

NPI: 1508430661
Provider Name (Legal Business Name): OBL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14804 N CAVE CREEK RD STE 200
PHOENIX AZ
85032-4945
US

IV. Provider business mailing address

202 E EARLL DR STE 360
PHOENIX AZ
85012-2677
US

V. Phone/Fax

Practice location:
  • Phone: 480-240-5613
  • Fax: 480-205-1063
Mailing address:
  • Phone: 480-788-5621
  • Fax: 480-779-1277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. KIUP KIM
Title or Position: FOUNDER / CEO
Credential: MD
Phone: 480-788-5621