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General NPI Number Information
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NPI Number | 1861893000
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Entity Type | Individual
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Provider Name | SUSAN KIM MS, RD, CNSC
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Gender | Female
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Dates
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Enumeration Date | 09/08/2014
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 21011 STORRS RD
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City | SACKETS HARBOR
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State | NY
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Zip | 13685-3172
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Country | US
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Telephone | 720-771-6691
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Fax | 720-771-6691
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Provider Business Mailing Address
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Address Line | 21011 STORRS ROAD
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City | SACKETS HARBOR
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State | NY
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Zip | 13685
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Country | US
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Telephone | 720-771-6691
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 1105343
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License Number State | CO
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