Provider Demographics
NPI:1932477106
Name:KIM, MINSU
Entity Type:Individual
Prefix:MR
First Name:MINSU
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 1:435 W CENTER STREET PROMENADE
Mailing Address - Street 2:UNIT 421
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3782
Mailing Address - Country:US
Mailing Address - Phone:858-414-3600
Mailing Address - Fax:
Practice Address - Street 1:435 W CENTER STREET PROMENADE
Practice Address - Street 2:UNIT 421
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-3782
Practice Address - Country:US
Practice Address - Phone:858-414-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFQ633ZMedicare PIN