Provider Demographics
NPI:1235109505
Name:KIM, KWANG (RD)
Entity Type:Individual
Prefix:MR
First Name:KWANG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 3905
Mailing Address - Street 2:
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033-3905
Mailing Address - Country:US
Mailing Address - Phone:928-697-4281
Mailing Address - Fax:928-697-4145
Practice Address - Street 1:KAYENTA PHS HEALTH CLINIC
Practice Address - Street 2:HWY 160 AND 163
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033
Practice Address - Country:US
Practice Address - Phone:928-697-4000
Practice Address - Fax:928-697-4145
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered