MEDICARE: HYEON KIM M.ED, ATC, CSCS

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	2255A2300X	Athletic Trainer	1079	AL

General Provider Information

NPI Number	:	1104231976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HYEON KIM M.ED, ATC, CSCS

Provider Business Mailing Address
First Line	:	1215 MULBERRY ST
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36106-1130
Country	:	US
Telephone Number	:	334-782-1976
Fax Number	:

Provider Business Practice Location Address
First Line	:	1215 MULBERRY ST
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36106-1130
Country	:	US
Telephone Number	:	334-782-1976
Fax Number	:

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

Provider Enumeration Date	:	06/30/2014
Last Update Date	:	06/30/2014

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