Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | DC36169 | CA |
NPI | 1003574013 |
---|---|
Provider Name | Dr. Jungtae Kim |
First Address | Buena Park, CA 90621-1893 |
Second Address | Montclair, CA 91763-2339 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/12/2021 |
Last Update Date | 07/12/2021 |