Provider Demographics
NPI:1649868696
Name:KIM, KENDRICK SANGYEOP
Entity type:Individual
Prefix:
First Name:KENDRICK
Middle Name:SANGYEOP
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KENNY
Other - Middle Name:S
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1927 CHATHAM PLACE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-4770
Mailing Address - Country:US
Mailing Address - Phone:732-554-7999
Mailing Address - Fax:
Practice Address - Street 1:1590 TROPIC PARK DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-6323
Practice Address - Country:US
Practice Address - Phone:732-554-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2023-01-12
Deactivation Date:2022-12-30
Deactivation Code:
Reactivation Date:2023-01-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator