Provider Demographics
NPI:1497521355
Name:KIM, JUSTIN (DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:JONG
Other - Middle Name:HYEON
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28618 MAPLE RED DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-1290
Mailing Address - Country:US
Mailing Address - Phone:469-274-3244
Mailing Address - Fax:
Practice Address - Street 1:373 E 10TH AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:CO
Practice Address - Zip Code:81073-1699
Practice Address - Country:US
Practice Address - Phone:719-523-4501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1385782225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist