Healthcare Provider Details

I. General information

NPI: 1275690927
Provider Name (Legal Business Name): KIM ASSOCIATES MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1433 W MERCED AVE STE 217
WEST COVINA CA
91790-3402
US

IV. Provider business mailing address

1433 W MERCED AVE STE 217
WEST COVINA CA
91790-3402
US

V. Phone/Fax

Practice location:
  • Phone: 626-917-1924
  • Fax: 626-337-8434
Mailing address:
  • Phone: 626-917-1924
  • Fax: 626-337-8434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA39454
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA38835
License Number StateCA

VIII. Authorized Official

Name: JAE M. KIM
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.D.
Phone: 626-917-1924