Healthcare Provider Details

I. General information

NPI: 1649736265
Provider Name (Legal Business Name): SOO KIM MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY KIM MS

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12465 LEWIS ST STE 102
GARDEN GROVE CA
92840-4658
US

IV. Provider business mailing address

PO BOX 740780
ATLANTA GA
30374-0780
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax:
Mailing address:
  • Phone: 855-223-7123
  • Fax: 619-374-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-62832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: