Provider Demographics
NPI:1942867874
Name:KIM, BACKHO (PHYSICAL THERAPY)
Entity Type:Individual
Prefix:
First Name:BACKHO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PHYSICAL THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6019 ROOSEVELT AVE STE 221
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4375
Mailing Address - Country:US
Mailing Address - Phone:929-232-5758
Mailing Address - Fax:
Practice Address - Street 1:6019 ROOSEVELT AVE STE 221
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-4375
Practice Address - Country:US
Practice Address - Phone:929-232-5758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-27
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038794225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty