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General NPI Number Information
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NPI Number | 1093945891
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Entity Type | Organization
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Legal Business Name | LAKESIDE PHYSICAL THERAPY, INC.
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Dates
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Enumeration Date | 07/15/2009
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Last Update Date | 07/15/2009
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Provider Practice Location Address
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Address Line | 27722 VISTA DEL LAGO A1
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City | MISSION VIEJO
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State | CA
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Zip | 92692-1133
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Country | US
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Telephone | 949-842-5735
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Fax |
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Provider Business Mailing Address
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Address Line | 23216 STELLA CT
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City | LAKE FOREST
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State | CA
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Zip | 92630-5336
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Country | US
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Telephone | 949-707-5442
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | FRED HYUNGSHIK KIM
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Credential | DPT
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Telephone | 949-707-5442
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 28555
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License Number State | CA
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