Provider Demographics
NPI:1760199939
Name:KIM, JOHNNY
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
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 1:1945 ROLLING HILLS CIR
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-3738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 BEVERLY DR
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-4319
Practice Address - Country:US
Practice Address - Phone:785-787-2303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver