Provider Demographics
NPI:1003405846
Name:KIM, KEN SANGBOEM
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:SANGBOEM
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17393
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92623-7393
Mailing Address - Country:US
Mailing Address - Phone:949-439-6109
Mailing Address - Fax:
Practice Address - Street 1:265 S ANITA DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3355
Practice Address - Country:US
Practice Address - Phone:949-439-6109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)