Healthcare Provider Details

I. General information

NPI: 1225661515
Provider Name (Legal Business Name): KENNETH IM DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2020
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 W 8TH ST STE 100
LOS ANGELES CA
90017-4422
US

IV. Provider business mailing address

13425 BEACHNUTT CT
LA MIRADA CA
90638-6559
US

V. Phone/Fax

Practice location:
  • Phone: 213-401-1970
  • Fax:
Mailing address:
  • Phone: 714-287-4964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: