Healthcare Provider Details

I. General information

NPI: 1386572972
Provider Name (Legal Business Name): CHRIS KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5495 OLD NATIONAL HWY
ATLANTA GA
30349-3252
US

IV. Provider business mailing address

1818 SW 4TH AVE APT 224
PORTLAND OR
97201-5517
US

V. Phone/Fax

Practice location:
  • Phone: 470-336-3683
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: