Provider Demographics
NPI:1417169145
Name:KIM, BRINA
Entity Type:Individual
Prefix:MS
First Name:BRINA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:554 E FOOTHILL BLVD STE 116
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1222
Mailing Address - Country:US
Mailing Address - Phone:909-599-8818
Mailing Address - Fax:909-599-8898
Practice Address - Street 1:554 E FOOTHILL BLVD STE 116
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1222
Practice Address - Country:US
Practice Address - Phone:909-599-8818
Practice Address - Fax:909-599-8898
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7841171100000X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No171100000XOther Service ProvidersAcupuncturist