Healthcare Provider Details

I. General information

NPI: 1548360399
Provider Name (Legal Business Name): YOUNG SONG KIM, MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80539 PEBBLE BCH
LA QUINTA CA
92253-4627
US

IV. Provider business mailing address

80539 PEBBLE BCH
LA QUINTA CA
92253-4627
US

V. Phone/Fax

Practice location:
  • Phone: 760-564-0241
  • Fax: 760-564-5941
Mailing address:
  • Phone: 760-564-0241
  • Fax: 760-564-5941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberC36986
License Number StateCA

VIII. Authorized Official

Name: DR. YOUNG SONG KIM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 760-564-0241