Healthcare Provider Details

I. General information

NPI: 1366315111
Provider Name (Legal Business Name): YE KYEOM IM OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CLARA IM OTD

II. Dates (important events)

Enumeration Date: 09/27/2025
Last Update Date: 09/27/2025
Certification Date: 09/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 BROOKHOLLOW DR STE 37
SANTA ANA CA
92705-5427
US

IV. Provider business mailing address

17146 FIRST LIGHT LN
RIVERSIDE CA
92503-8710
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-7330
  • Fax: 949-727-2193
Mailing address:
  • Phone: 951-269-1031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number28235
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: