MEDICARE: KENNETH K KIM, A MEDICAL CORPORATION

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	207Q00000X	Family Medicine Physician	G71557	CA

General Provider Information

NPI Number	:	1295004034
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNETH K KIM, A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	P.O. BOX 741519
Second Line	:	SUITE 106
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-1417
Country	:	US
Telephone Number	:	213-234-5575
Fax Number	:	213-427-9850

Provider Business Practice Location Address
First Line	:	520 S VIRGIL AVE
Second Line	:	SUITE 106
City	:	LOS ANGELES
State	:	CA
Zip	:	90020-1417
Country	:	US
Telephone Number	:	213-234-5575
Fax Number	:	213-427-9850

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KENNETH K KIM
Credential	:	M.D.
Telephone Number	:	213-234-5575

Provider Enumeration Date	:	12/23/2011
Last Update Date	:	12/23/2011

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