Provider Demographics
NPI:1912026196
Name:KIMMI, SSUNG J (DC)
Entity Type:Individual
Prefix:
First Name:SSUNG
Middle Name:J
Last Name:KIMMI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12795 SW 3RD ST.
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005
Mailing Address - Country:US
Mailing Address - Phone:503-641-4244
Mailing Address - Fax:503-641-0551
Practice Address - Street 1:12795 SW 3RD ST.
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005
Practice Address - Country:US
Practice Address - Phone:503-641-4244
Practice Address - Fax:503-641-0551
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273444111N00000X
OR3444111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR858521000OtherHEALTH INSURANCE PROVIDER
OR858521000OtherHEALTH INSURANCE PROVIDER
ORU97679Medicare UPIN