Healthcare Provider Details

I. General information

NPI: 1285175109
Provider Name (Legal Business Name): STEPHEN KIM CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 E 47TH ST STE 204
CHICAGO IL
60653-4695
US

IV. Provider business mailing address

1304 E 47TH ST STE 204
CHICAGO IL
60653-4695
US

V. Phone/Fax

Practice location:
  • Phone: 312-757-5270
  • Fax:
Mailing address:
  • Phone: 312-757-5270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number213.000297
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number211.000412
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: