Healthcare Provider Details

I. General information

NPI: 1619987054
Provider Name (Legal Business Name): WAYNE W KIM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12362 BEACH BLVD STE 10
STANTON CA
90680-3944
US

IV. Provider business mailing address

12362 BEACH BLVD STE 10
STANTON CA
90680-3944
US

V. Phone/Fax

Practice location:
  • Phone: 714-248-9500
  • Fax: 714-622-4943
Mailing address:
  • Phone: 714-248-9500
  • Fax: 714-622-4943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00001562
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberOP00001562
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: