Provider Demographics
NPI:1982826525
Name:KIM, IL NAM (LAC)
Entity Type:Individual
Prefix:
First Name:IL
Middle Name:NAM
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23978 BOULDER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-4151
Mailing Address - Country:US
Mailing Address - Phone:714-595-7377
Mailing Address - Fax:
Practice Address - Street 1:1485 SPRUCE ST
Practice Address - Street 2:SUITE P
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2445
Practice Address - Country:US
Practice Address - Phone:951-682-8167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 11248171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor