Provider Demographics
NPI:1477310142
Name:KIM, GRIGORIY (DPT)
Entity Type:Individual
Prefix:
First Name:GRIGORIY
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 1:470 N CIVIC DR APT 313
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-3344
Mailing Address - Country:US
Mailing Address - Phone:415-745-5047
Mailing Address - Fax:
Practice Address - Street 1:2280 DIAMOND BLVD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5750
Practice Address - Country:US
Practice Address - Phone:925-269-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3057172251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic