Provider Demographics
NPI:1922793371
Name:KIM, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
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 1:12905 SW WILMINGTON LN
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-1794
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4025 MERCANTILE DR STE 105
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2518
Practice Address - Country:US
Practice Address - Phone:503-919-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6301111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor