Provider Demographics
NPI:1578065553
Name:KIM, STANLEY SOOYOUN
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:SOOYOUN
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 1:609 HAZELTON ST
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:CA
Mailing Address - Zip Code:93252
Mailing Address - Country:US
Mailing Address - Phone:661-416-4096
Mailing Address - Fax:
Practice Address - Street 1:609 HAZELTON ST
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:CA
Practice Address - Zip Code:93252
Practice Address - Country:US
Practice Address - Phone:661-416-4096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD5481793172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver