Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | SL5837 | CA |
NPI | 1215474416 |
---|---|
Provider Name | Samuel Kim |
First Address | Los Angeles, CA 90020-3448 |
Second Address | Los Angeles, CA 90020-3448 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/01/2017 |
Last Update Date | 25/01/2017 |