Healthcare Provider Details

I. General information

NPI: 1992312904
Provider Name (Legal Business Name): SAE KIM NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7677 CENTER AVE STE 405
HUNTINGTON BEACH CA
92647-3098
US

IV. Provider business mailing address

451 W LINCOLN AVE STE 100
ANAHEIM CA
92805-2912
US

V. Phone/Fax

Practice location:
  • Phone: 171-434-5438
  • Fax:
Mailing address:
  • Phone: 714-503-6550
  • Fax: 714-409-3094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95015173
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: