Healthcare Provider Details

I. General information

NPI: 1972466316
Provider Name (Legal Business Name): DAESUNG KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4291 HADLEY PARK RD
SUGAR HILL GA
30518-6422
US

IV. Provider business mailing address

4291 HADLEY PARK RD
SUGAR HILL GA
30518-6422
US

V. Phone/Fax

Practice location:
  • Phone: 918-896-2255
  • Fax:
Mailing address:
  • Phone: 918-896-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN327866
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: