Provider Demographics
NPI:1588027460
Name:YIM, TAE
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:
Last Name:YIM
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 1:725 E 17TH ST
Mailing Address - Street 2:APT G
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606
Mailing Address - Country:US
Mailing Address - Phone:510-990-5910
Mailing Address - Fax:
Practice Address - Street 1:725 E 17TH ST
Practice Address - Street 2:APT G
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-2952
Practice Address - Country:US
Practice Address - Phone:510-990-5910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver