Provider Demographics
NPI:1679985535
Name:KIM, YONGHA (PT)
Entity Type:Individual
Prefix:
First Name:YONGHA
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 1:11405 FULBOURN CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-8341
Mailing Address - Country:US
Mailing Address - Phone:571-835-5038
Mailing Address - Fax:
Practice Address - Street 1:15015 41ST AVE
Practice Address - Street 2:#2
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4917
Practice Address - Country:US
Practice Address - Phone:571-835-5038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-27
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294694225100000X
VA2305208592225100000X
NY37344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist