Provider Demographics
NPI:1073796843
Name:JAE J. KIM, M.D.
Entity Type:Organization
Organization Name:JAE J. KIM, M.D.
Other - Org Name:SHAFTER RURAL HEALTH CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-746-4937
Mailing Address - Street 1:565 KERN ST
Mailing Address - Street 2:
Mailing Address - City:SHAFTER
Mailing Address - State:CA
Mailing Address - Zip Code:93263-2133
Mailing Address - Country:US
Mailing Address - Phone:661-746-4937
Mailing Address - Fax:
Practice Address - Street 1:565 KERN ST
Practice Address - Street 2:
Practice Address - City:SHAFTER
Practice Address - State:CA
Practice Address - Zip Code:93263-2133
Practice Address - Country:US
Practice Address - Phone:661-746-4937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38875261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53819FMedicaid
CA00A388750Medicare PIN
CARHM53819FMedicaid