Provider Demographics
NPI:1811355944
Name:KIM, JEONGHO (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:JEONGHO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 E BURR OAK DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-1813
Mailing Address - Country:US
Mailing Address - Phone:929-233-4979
Mailing Address - Fax:
Practice Address - Street 1:1052 S ELMHURST RD
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-4240
Practice Address - Country:US
Practice Address - Phone:847-439-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033030225100000X
IL070021834225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist