Healthcare Provider Details

I. General information

NPI: 1811734346
Provider Name (Legal Business Name): SUZANNE TERESA KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 CROSSFIT LN
RAEFORD NC
28376-1080
US

IV. Provider business mailing address

595 WINDING CREEK RD APT F
FAYETTEVILLE NC
28305-5165
US

V. Phone/Fax

Practice location:
  • Phone: 910-992-9566
  • Fax:
Mailing address:
  • Phone: 910-992-9566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number21044
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: