MEDICARE: SUNG JAY KIM PT

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	225100000X	Physical Therapist	298747	CA
2	225100000X	Physical Therapist	PT298747	CA

General Provider Information

NPI Number	:	1871194910
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUNG JAY KIM PT

Provider Business Mailing Address
First Line	:	2825 PLAZA DEL AMO UNIT 130
Second Line	:
City	:	TORRANCE
State	:	CA
Zip	:	90503-9377
Country	:	US
Telephone Number	:	310-701-7427
Fax Number	:

Provider Business Practice Location Address
First Line	:	1912 S PACIFIC COAST HWY
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-6118
Country	:	US
Telephone Number	:	310-540-5758
Fax Number	:

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

Provider Enumeration Date	:	11/05/2020
Last Update Date	:	11/05/2020

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