Healthcare Provider Details

I. General information

NPI: 1053274720
Provider Name (Legal Business Name): VIVIAN KIM
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12182 1/2 VENTURA BLVD
STUDIO CITY CA
91604-2517
US

IV. Provider business mailing address

5363 EDGEWOOD PL APT B
LOS ANGELES CA
90019-6761
US

V. Phone/Fax

Practice location:
  • Phone: 818-921-7335
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT36150-TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: