Provider Demographics
NPI:1568985463
Name:POWER HEALING MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:POWER HEALING MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOONG
Authorized Official - Middle Name:GAP
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-965-0500
Mailing Address - Street 1:1251 W REDONDO BEACH BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-3464
Mailing Address - Country:US
Mailing Address - Phone:310-965-0500
Mailing Address - Fax:310-965-0055
Practice Address - Street 1:1251 W REDONDO BEACH BLVD FL 3
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3464
Practice Address - Country:US
Practice Address - Phone:310-965-0500
Practice Address - Fax:310-965-0055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39214207V00000X
CACA18720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861527897Medicaid