Provider Demographics
NPI:1063697456
Name:JULIE KANG-KIM OPTOMETRIC CORPORATION
Entity type:Organization
Organization Name:JULIE KANG-KIM OPTOMETRIC CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KANG-KIM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:818-786-0796
Mailing Address - Street 1:7100 VAN NUYS BLVD
Mailing Address - Street 2:208
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3063
Mailing Address - Country:US
Mailing Address - Phone:818-786-0796
Mailing Address - Fax:818-786-1706
Practice Address - Street 1:7100 VAN NUYS BLVD
Practice Address - Street 2:208
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3063
Practice Address - Country:US
Practice Address - Phone:818-786-0796
Practice Address - Fax:818-786-1706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9480T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD000040Medicaid
CAGSD000040Medicaid