Provider Demographics
NPI:1164538369
Name:PETER P. KIM
Entity Type:Organization
Organization Name:PETER P. KIM
Other - Org Name:RIVERSIDE MEDICAL SUPPLY, CO.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:P
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:951-343-0428
Mailing Address - Street 1:10280 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5357
Mailing Address - Country:US
Mailing Address - Phone:951-343-0428
Mailing Address - Fax:951-343-0438
Practice Address - Street 1:10280 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5357
Practice Address - Country:US
Practice Address - Phone:951-343-0428
Practice Address - Fax:951-343-0438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44384332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17867OtherHMDR EXEMPTEE LICENSE
CA44384OtherHOME MED DEVICE RETAIL
CA9424937Medicaid
5448620001Medicare PIN
CA9424937Medicaid