Provider Demographics
NPI:1497041438
Name:KIM, PETER P
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:P
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10280 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5357
Mailing Address - Country:US
Mailing Address - Phone:951-343-0428
Mailing Address - Fax:951-343-0438
Practice Address - Street 1:720 S. RAMONA AVE.
Practice Address - Street 2:SUITE 103
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-2147
Practice Address - Country:US
Practice Address - Phone:951-735-1677
Practice Address - Fax:951-735-7611
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53282225000000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5448620001Medicare NSC