Provider Demographics
NPI:1497274617
Name:IM, YOUNG VIN
Entity Type:Individual
Prefix:
First Name:YOUNG
Middle Name:VIN
Last Name:IM
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 1:8051 MADIA CIR
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1926
Mailing Address - Country:US
Mailing Address - Phone:714-402-2802
Mailing Address - Fax:
Practice Address - Street 1:1700 ADAMS AVE STE 103
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4865
Practice Address - Country:US
Practice Address - Phone:714-556-2288
Practice Address - Fax:714-435-1745
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17904225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist