Provider Demographics
NPI:1225730237
Name:LIM, JI SU (DPT)
Entity Type:Individual
Prefix:
First Name:JI SU
Middle Name:
Last Name:LIM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12465 LEWIS ST STE 101
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4658
Mailing Address - Country:US
Mailing Address - Phone:714-703-8477
Mailing Address - Fax:
Practice Address - Street 1:24361 EL TORO RD STE 140
Practice Address - Street 2:
Practice Address - City:LAGUNA WOODS
Practice Address - State:CA
Practice Address - Zip Code:92637-8898
Practice Address - Country:US
Practice Address - Phone:949-694-9988
Practice Address - Fax:949-694-9977
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT303893225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist