Healthcare Provider Details

I. General information

NPI: 1497942932
Provider Name (Legal Business Name): SOUTHERN CALIFRONIA SPECIALISTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11190 WARNER AVE SUITE 307
FOUNTAIN VALLEY CA
92708-4019
US

IV. Provider business mailing address

11190 WARNER AVE SUITE 307
FOUNTAIN VALLEY CA
92708-4019
US

V. Phone/Fax

Practice location:
  • Phone: 714-545-6400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH KIM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-506-8094