MEDICARE: NIPPON CLINIC AND NOGUCHI NINGEN DOCK LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1326058355
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NIPPON CLINIC AND NOGUCHI NINGEN DOCK LLC

Provider Business Mailing Address
First Line	:	3707 CONVOY ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-3754
Country	:	US
Telephone Number	:	858-560-8910
Fax Number	:	858-560-8011

Provider Business Practice Location Address
First Line	:	3707 CONVOY ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-3754
Country	:	US
Telephone Number	:	858-560-8910
Fax Number	:	858-560-8011

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. ILDONG KIM
Credential	:	MD
Telephone Number	:	858-560-8910

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	08/22/2020

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