Provider Demographics
NPI:1871194910
Name:KIM, SUNG JAY (PT)
Entity Type:Individual
Prefix:
First Name:SUNG JAY
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 1:2825 PLAZA DEL AMO UNIT 130
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-9377
Mailing Address - Country:US
Mailing Address - Phone:310-701-7427
Mailing Address - Fax:
Practice Address - Street 1:1912 S PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-6118
Practice Address - Country:US
Practice Address - Phone:310-540-5758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298747225100000X
CAPT298747225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist