=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538906912
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. BECKY MIHAE KIM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2024
-----------------------------------------------------
Last Update Date | 07/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3557 BRADSHAW RD STE 2E
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95827-3373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-361-2020
-----------------------------------------------------
Fax | 916-361-0433
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3557 BRADSHAW RD STE 2E
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95827-3373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-508-2848
-----------------------------------------------------
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 | 10618T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------