Provider Demographics
NPI:1205560034
Name:JENNIFER KIM, OD. A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JENNIFER KIM, OD. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-367-9484
Mailing Address - Street 1:5368 SHEMIRAN ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2378
Mailing Address - Country:US
Mailing Address - Phone:310-367-9484
Mailing Address - Fax:
Practice Address - Street 1:2209 E BASELINE RD STE 400
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-7902
Practice Address - Country:US
Practice Address - Phone:909-765-5303
Practice Address - Fax:909-765-5304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty