Healthcare Provider Details

I. General information

NPI: 1063201390
Provider Name (Legal Business Name): SOJEONG KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E BROADWAY STE 103557
EUGENE OR
97401-3114
US

IV. Provider business mailing address

101 E BROADWAY STE 103557
EUGENE OR
97401-3114
US

V. Phone/Fax

Practice location:
  • Phone: 541-357-9764
  • Fax:
Mailing address:
  • Phone: 458-245-7472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: