Healthcare Provider Details

I. General information

NPI: 1497497085
Provider Name (Legal Business Name): HEIDI GINA KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 HARBOR BLVD STE C2
COSTA MESA CA
92626-1518
US

IV. Provider business mailing address

3303 HARBOR BLVD STE C2
COSTA MESA CA
92626-1518
US

V. Phone/Fax

Practice location:
  • Phone: 949-996-4354
  • Fax:
Mailing address:
  • Phone: 858-886-9654
  • 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: