MEDICARE: CHRISTINE 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	101Y00000X	Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3024423174	OTHER		IDENTIFICATION

General Provider Information

NPI Number	:	1073255477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE KIM

Provider Business Mailing Address
First Line	:	4755 RASPBERRY PL
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95129-1936
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4755 RASPBERRY PL
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95129-1936
Country	:	US
Telephone Number	:	302-442-3174
Fax Number	:

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

Provider Enumeration Date	:	04/07/2022
Last Update Date	:	04/07/2022

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Directions to “ CHRISTINE KIM ” Practice Location

Language	Start Address	Practice Location

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