Provider Demographics
NPI:1386028801
Name:KIM, TAE JIN
Entity Type:Individual
Prefix:
First Name:TAE JIN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19904 47TH AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-3955
Mailing Address - Country:US
Mailing Address - Phone:929-373-5772
Mailing Address - Fax:914-462-4372
Practice Address - Street 1:19904 47TH AVE APT 1
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-3955
Practice Address - Country:US
Practice Address - Phone:929-373-5772
Practice Address - Fax:914-462-4372
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist