Provider Demographics
NPI:1023032406
Name:KIM, CHUNG JA
Entity Type:Individual
Prefix:MRS
First Name:CHUNG
Middle Name:JA
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 S WESTERN AVE
Mailing Address - Street 2:STE A
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-3804
Mailing Address - Country:US
Mailing Address - Phone:213-385-9133
Mailing Address - Fax:213-385-3121
Practice Address - Street 1:333 S WESTERN AVE
Practice Address - Street 2:STE A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-3804
Practice Address - Country:US
Practice Address - Phone:213-385-9133
Practice Address - Fax:213-385-3121
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME01438FMedicaid
CA3889200001Medicare NSC