=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922793371
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD KIM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2023
-----------------------------------------------------
Last Update Date | 12/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12005 SW 70TH AVE
-----------------------------------------------------
City | TIGARD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97223-9634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-208-3579
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12905 SW WILMINGTON LN
-----------------------------------------------------
City | TIGARD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97224-1794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 6301
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------