Provider Demographics
NPI:1780903963
Name:KIM, KEI CHUNG (OMD)
Entity type:Individual
Prefix:DR
First Name:KEI
Middle Name:CHUNG
Last Name:KIM
Suffix:
Gender:M
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11130 MAGNOLIA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3675
Mailing Address - Country:US
Mailing Address - Phone:951-785-1133
Mailing Address - Fax:
Practice Address - Street 1:11130 MAGNOLIA AVE STE B
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3675
Practice Address - Country:US
Practice Address - Phone:951-785-1133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC671171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist