Provider Demographics
NPI:1275690927
Name:KIM ASSOCIATES MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:KIM ASSOCIATES MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-917-1924
Mailing Address - Street 1:1433 W MERCED AVE STE 217
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3402
Mailing Address - Country:US
Mailing Address - Phone:626-917-1924
Mailing Address - Fax:626-337-8434
Practice Address - Street 1:1433 W MERCED AVE STE 217
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3402
Practice Address - Country:US
Practice Address - Phone:626-917-1924
Practice Address - Fax:626-337-8434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38835207R00000X
CAA39454208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689735953Medicaid
CAC03987Medicare UPIN
CAW22266Medicare PIN