Healthcare Provider Details

I. General information

NPI: 1326262502
Provider Name (Legal Business Name): SUNG W. KIM M.DIV.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18623 GALE AVE
CITY OF INDUSTRY CA
91748-1342
US

IV. Provider business mailing address

17109 HIGHWOOD RD
HACIENDA HEIGHTS CA
91745-6757
US

V. Phone/Fax

Practice location:
  • Phone: 626-839-0300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: