MEDICARE: CRYSTAL 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	33716	CA

General Provider Information

NPI Number	:	1356861645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL KIM

Provider Business Mailing Address
First Line	:	21600 HAWTHORNE BLVD
Second Line	:
City	:	TORRANCE
State	:	CA
Zip	:	90503-5710
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	21600 HAWTHORNE BLVD
Second Line	:
City	:	TORRANCE
State	:	CA
Zip	:	90503-5710
Country	:	US
Telephone Number	:	310-214-0409
Fax Number	:

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

Provider Enumeration Date	:	06/27/2017
Last Update Date	:	03/17/2018

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Directions to “ CRYSTAL KIM ” Practice Location

Language	Start Address	Practice Location

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