Provider Demographics
NPI:1477235505
Name:KIM, MO (ATC)
Entity Type:Individual
Prefix:MR
First Name:MO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12517 HILLGATE LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-2420
Mailing Address - Country:US
Mailing Address - Phone:804-337-8809
Mailing Address - Fax:
Practice Address - Street 1:1971 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24515-0002
Practice Address - Country:US
Practice Address - Phone:804-337-8809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI20000540042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty