Provider Demographics
NPI:1396054789
Name:KIM, SOOMI (DPT)
Entity type:Individual
Prefix:
First Name:SOOMI
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4282 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-3503
Mailing Address - Country:US
Mailing Address - Phone:570-856-2297
Mailing Address - Fax:
Practice Address - Street 1:212 9TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-4456
Practice Address - Country:US
Practice Address - Phone:570-856-2297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36790225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist