Healthcare Provider Details

I. General information

NPI: 1104465541
Provider Name (Legal Business Name): SAM KIM PHYSICIAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 02/10/2026
Certification Date: 02/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 BALBOA BLVD STE 326
ENCINO CA
91316-5214
US

IV. Provider business mailing address

5400 BALBOA BLVD STE 326
ENCINO CA
91316-5214
US

V. Phone/Fax

Practice location:
  • Phone: 818-789-0941
  • Fax: 818-789-6726
Mailing address:
  • Phone: 818-939-4511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL SUNGWON KIM
Title or Position: CEO
Credential: M.D.
Phone: 818-939-4511