Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1174297360 |
---|---|
Provider Name | Minsoo Kim |
First Address | Los Alamitos, CA 90720-2381 |
Second Address | Costa Mesa, CA 92626-3033 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2021 |
Last Update Date | 02/08/2021 |