Healthcare Provider Details

I. General information

NPI: 1073962999
Provider Name (Legal Business Name): JAY KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2016
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12912 BROOKHURST ST STE 480
GARDEN GROVE CA
92840-4867
US

IV. Provider business mailing address

12912 BROOKHURST ST STE 480
GARDEN GROVE CA
92840-4867
US

V. Phone/Fax

Practice location:
  • Phone: 714-636-9095
  • Fax:
Mailing address:
  • Phone: 714-636-9095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: