Provider Demographics
NPI:1336677012
Name:SIM, MIKE CHARLES JR
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:CHARLES
Last Name:SIM
Suffix:JR
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 1:12201 VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-3107
Mailing Address - Country:US
Mailing Address - Phone:626-350-9922
Mailing Address - Fax:626-350-9923
Practice Address - Street 1:12201 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91732-3107
Practice Address - Country:US
Practice Address - Phone:626-350-9922
Practice Address - Fax:626-350-9923
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95770332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies