Provider Demographics
NPI:1275242083
Name:KIM YOUNGRAE MEDICAL, INC
Entity Type:Organization
Organization Name:KIM YOUNGRAE MEDICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:YOUNGRAE
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-588-4037
Mailing Address - Street 1:5730 BEACH BLVD
Mailing Address - Street 2:#200
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-4305
Mailing Address - Country:US
Mailing Address - Phone:714-588-4024
Mailing Address - Fax:
Practice Address - Street 1:5730 BEACH BLVD
Practice Address - Street 2:#200
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-4305
Practice Address - Country:US
Practice Address - Phone:714-588-4024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-21
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty