Provider Demographics
NPI:1629202163
Name:KIM, MILA (PT)
Entity Type:Individual
Prefix:MRS
First Name:MILA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5610 RIVER WAY
Mailing Address - Street 2:#C
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-1744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5610 RIVER WAY
Practice Address - Street 2:#C
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-1744
Practice Address - Country:US
Practice Address - Phone:718-873-7779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35563225100000X
NY024118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist