Healthcare Provider Details

I. General information

NPI: 1811236318
Provider Name (Legal Business Name): DANIEL E KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIR
CAMP PENDLETON CA
92055-5191
US

IV. Provider business mailing address

PO BOX 555191
CAMP PENDLETON CA
92055-5191
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1288
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.015130
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number79423
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: