Provider Demographics
NPI:1427393628
Name:KIM, JUSTIN INSUN (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:INSUN
Last Name:KIM
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13355 W CHOCTAW TRL
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:388 YPAO RD
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3701
Practice Address - Country:US
Practice Address - Phone:671-646-8881
Practice Address - Fax:671-648-2548
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.019618225100000X
GUPT-137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU1427393628Medicaid