Healthcare Provider Details

I. General information

NPI: 1508272253
Provider Name (Legal Business Name): STELLA KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 E GARVEY AVE N STE A
WEST COVINA CA
91791-1500
US

IV. Provider business mailing address

1246 E ARROW HWY STE A
UPLAND CA
91786-4955
US

V. Phone/Fax

Practice location:
  • Phone: 266-009-4866
  • Fax:
Mailing address:
  • Phone: 909-931-9675
  • Fax: 909-931-3239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14985TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: