=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114033206
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHERINE KIM O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 09/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5169 VISTA DEL AMIGO
-----------------------------------------------------
City | YORBA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92886-4651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-701-0779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5169 VISTA DEL AMIGO
-----------------------------------------------------
City | YORBA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92886-4651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 10899T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------