Healthcare Provider Details

I. General information

NPI: 1619840303
Provider Name (Legal Business Name): HAE KYUN KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BEN HAE-KYUN KIM ATC

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 N IL ROUTE 31 FL 2
CRYSTAL LAKE IL
60012-3713
US

IV. Provider business mailing address

420 N IL ROUTE 31 FL 2
CRYSTAL LAKE IL
60012-3713
US

V. Phone/Fax

Practice location:
  • Phone: 708-456-4242
  • Fax:
Mailing address:
  • Phone: 708-835-7582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096005732
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: