Provider Demographics
NPI:1760544886
Name:KIM, SEONWEON (PT)
Entity Type:Individual
Prefix:
First Name:SEONWEON
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 1:472 W DUARTE RD
Mailing Address - Street 2:#A
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-9160
Mailing Address - Country:US
Mailing Address - Phone:626-294-9042
Mailing Address - Fax:
Practice Address - Street 1:472 W DUARTE RD
Practice Address - Street 2:#A
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-9160
Practice Address - Country:US
Practice Address - Phone:626-294-9042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32717225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT32717AMedicare ID - Type UnspecifiedPT