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General NPI Number Information
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NPI Number | 1659516094
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Entity Type | Organization
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Legal Business Name | ILKYOON KIM MD A PROF CORP
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Dates
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Enumeration Date | 12/15/2008
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Last Update Date | 04/12/2013
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Provider Practice Location Address
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Address Line | 15666 18TH AVE
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City | CLEARLAKE
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State | CA
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Zip | 95422-9336
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Country | US
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Telephone | 707-994-4210
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Fax | 707-994-0839
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Provider Business Mailing Address
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Address Line | 15666 18TH AVE P.O. BOX 5326
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City | CLEARLAKE
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State | CA
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Zip | 95422-9336
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Country | US
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Telephone | 707-994-4210
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Fax | 707-994-0839
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Authorized Official
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Title or Position | CEO
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Name | DR. ILKYOON KIM
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Credential | MD
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Telephone | 707-994-4210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | A-34081
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License Number State | CA
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