Provider Demographics
NPI:1104573336
Name:KIM, JONATHAN KIMIN (PT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:KIMIN
Last Name:KIM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5105
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5100
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:
Practice Address - Street 1:910 W WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-5201
Practice Address - Country:US
Practice Address - Phone:919-363-1957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP20268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP20268OtherMEDICAL LICENSE