Provider Demographics
NPI:1235597824
Name:KIM, TAEYONG (PT)
Entity Type:Individual
Prefix:
First Name:TAEYONG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9115 LAMONT AVE APT 2K
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-2731
Mailing Address - Country:US
Mailing Address - Phone:909-815-1269
Mailing Address - Fax:
Practice Address - Street 1:9115 LAMONT AVE APT 2K
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-2731
Practice Address - Country:US
Practice Address - Phone:909-815-1269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25837225100000X
NY039812225100000X
VA2305209975225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist