Healthcare Provider Details

I. General information

NPI: 1588027460
Provider Name (Legal Business Name): TAE YIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 E 17TH ST APT G
OAKLAND CA
94606-2952
US

IV. Provider business mailing address

725 E 17TH ST APT G
OAKLAND CA
94606
US

V. Phone/Fax

Practice location:
  • Phone: 510-990-5910
  • Fax:
Mailing address:
  • Phone: 510-990-5910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: