Provider Demographics
NPI:1043073034
Name:KIM, JI
Entity Type:Individual
Prefix:
First Name:JI
Middle Name:
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 1:2623 S DEFRAME CIR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-4736
Mailing Address - Country:US
Mailing Address - Phone:770-851-5404
Mailing Address - Fax:
Practice Address - Street 1:2623 S DEFRAME CIR
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-4736
Practice Address - Country:US
Practice Address - Phone:770-851-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO88-1385157225700000X
CO881385157225700000X
COMT.0024725225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist