=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033361720
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHUNG-LIM KIM M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2008
-----------------------------------------------------
Last Update Date | 04/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 E LA PALMA AVE STE 101
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92805-1636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-399-3480
-----------------------------------------------------
Fax | 714-399-3481
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 161 AVENIDA CABRILLO
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92672-4040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-369-6700
-----------------------------------------------------
Fax | 949-492-4081
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | A45578
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------