Healthcare Provider Details

I. General information

NPI: 1578409678
Provider Name (Legal Business Name): DAEBEOMM KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5460 E LA PALMA AVE
ANAHEIM CA
92807-2023
US

IV. Provider business mailing address

6456 BACH CIR
BUENA PARK CA
90621-3104
US

V. Phone/Fax

Practice location:
  • Phone: 714-463-7500
  • Fax:
Mailing address:
  • Phone: 949-278-4847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: