Provider Demographics
NPI:1952304016
Name:KIM, TONY KYUNGSOO (DC)
Entity Type:Individual
Prefix:DR
First Name:TONY
Middle Name:KYUNGSOO
Last Name:KIM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24318 HEMLOCK AVE
Mailing Address - Street 2:E5
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7222
Mailing Address - Country:US
Mailing Address - Phone:951-485-1918
Mailing Address - Fax:951-346-5600
Practice Address - Street 1:2100 MARKET ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-9535
Practice Address - Country:US
Practice Address - Phone:502-244-9859
Practice Address - Fax:770-573-9513
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27102111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN08002884AOtherINDIANA LICENSE
IN08002884AOtherINDIANA LICENSE