Provider Demographics
NPI:1689849176
Name:KIM, JAE HYUN
Entity Type:Individual
Prefix:MISS
First Name:JAE
Middle Name:HYUN
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 1:1918 COLISEUM BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-3211
Mailing Address - Country:US
Mailing Address - Phone:336-294-7923
Mailing Address - Fax:336-294-3961
Practice Address - Street 1:1918 COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-3211
Practice Address - Country:US
Practice Address - Phone:336-294-7923
Practice Address - Fax:336-294-3961
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist