Provider Demographics
NPI:1417438375
Name:KIM, MAIN (DPT)
Entity Type:Individual
Prefix:
First Name:MAIN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 37TH STREET
Mailing Address - Street 2:UNIT 404
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087
Mailing Address - Country:US
Mailing Address - Phone:201-328-4323
Mailing Address - Fax:
Practice Address - Street 1:700 PALISADIUM DR
Practice Address - Street 2:
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010-3239
Practice Address - Country:US
Practice Address - Phone:201-917-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA0180000225100000X
NJ40QA01810000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist