Provider Demographics
NPI:1578861399
Name:KIM, MYUNGJIN (PT)
Entity Type:Individual
Prefix:
First Name:MYUNGJIN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12139 MOUNT VERNON AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5586
Mailing Address - Country:US
Mailing Address - Phone:909-370-3396
Mailing Address - Fax:909-783-4288
Practice Address - Street 1:12139 MOUNT VERNON AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5586
Practice Address - Country:US
Practice Address - Phone:909-370-3396
Practice Address - Fax:909-783-4288
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29866225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist