Provider Demographics
NPI:1730674169
Name:KIM, RAYCHEL LYN (OD)
Entity Type:Individual
Prefix:
First Name:RAYCHEL
Middle Name:LYN
Last Name:KIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 S MERIDIAN STE 926
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-3722
Mailing Address - Country:US
Mailing Address - Phone:253-391-2389
Mailing Address - Fax:
Practice Address - Street 1:3500 S MERIDIAN STE 926
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3722
Practice Address - Country:US
Practice Address - Phone:253-391-2389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD894152W00000X
WAOD60861947152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist