Healthcare Provider Details

I. General information

NPI: 1164538369
Provider Name (Legal Business Name): PETER P. KIM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10280 INDIANA AVE
RIVERSIDE CA
92503-5357
US

IV. Provider business mailing address

10280 INDIANA AVE
RIVERSIDE CA
92503-5357
US

V. Phone/Fax

Practice location:
  • Phone: 951-343-0428
  • Fax: 951-343-0438
Mailing address:
  • Phone: 951-343-0428
  • Fax: 951-343-0438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number44384
License Number StateCA

VIII. Authorized Official

Name: MR. PETER P KIM
Title or Position: OWNER
Credential: RN
Phone: 951-343-0428