Provider Demographics
NPI:1366840613
Name:KIM, ALICE (OD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 W AVENUE P
Mailing Address - Street 2:SUITE 737
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-3947
Mailing Address - Country:US
Mailing Address - Phone:661-575-9090
Mailing Address - Fax:
Practice Address - Street 1:1233 W AVENUE P
Practice Address - Street 2:SUITE 737
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-3947
Practice Address - Country:US
Practice Address - Phone:661-575-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15141TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist