=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174042485
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. KIM'S ADULT CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8100 TWISTED HICKORY RD
-----------------------------------------------------
City | BLADENBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28320-7010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-876-7301
-----------------------------------------------------
Fax | 910-648-5650
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8100 TWISTED HICKORY RD
-----------------------------------------------------
City | BLADENBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28320-7010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-876-7301
-----------------------------------------------------
Fax | 910-648-5650
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | DR. JONG WHAN KIM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 910-876-7301
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 200101455
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------