Provider Demographics
NPI:1083251946
Name:KIM, SO EUN
Entity Type:Individual
Prefix:
First Name:SO EUN
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 1:13031 RIVERSIDE WAY
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-2969
Mailing Address - Country:US
Mailing Address - Phone:213-330-5002
Mailing Address - Fax:
Practice Address - Street 1:13031 RIVERSIDE WAY
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-2969
Practice Address - Country:US
Practice Address - Phone:213-330-5002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty