MEDICARE: VIVIAN KIM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT36150-TLG	CA

General Provider Information

NPI Number	:	1053274720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIVIAN KIM

Provider Business Mailing Address
First Line	:	5363 EDGEWOOD PL APT B
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90019-6761
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12182 1/2 VENTURA BLVD
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-2517
Country	:	US
Telephone Number	:	818-921-7335
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2025
Last Update Date	:	12/08/2025

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Directions to “ VIVIAN KIM ” Practice Location

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