MEDICARE: ANDREW KIM 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

General Provider Information

NPI Number	:	1386404044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW KIM CSCS

Provider Business Mailing Address
First Line	:	TCU BOX 297730
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76129-0001
Country	:	US
Telephone Number	:	614-738-6627
Fax Number	:

Provider Business Practice Location Address
First Line	:	3005 STADIUM DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76129-0001
Country	:	US
Telephone Number	:	817-257-7665
Fax Number	:

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

Provider Enumeration Date	:	03/20/2024
Last Update Date	:	03/20/2024

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