Healthcare Provider Details

I. General information

NPI: 1982775524
Provider Name (Legal Business Name): JIENSUP KIM, M.D. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10431 COMMERCE ST SUITE A
REDLANDS CA
92374-2833
US

IV. Provider business mailing address

PO BOX 71
REDLANDS CA
92373-0021
US

V. Phone/Fax

Practice location:
  • Phone: 909-796-7700
  • Fax: 909-796-4383
Mailing address:
  • Phone: 909-370-0300
  • Fax: 909-370-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG75806
License Number StateCA

VIII. Authorized Official

Name: DR. JIENSUP KIM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 909-370-0300