Provider Demographics
NPI:1194339143
Name:KIM, KYUNGYEON (RD)
Entity type:Individual
Prefix:
First Name:KYUNGYEON
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 ROCKVIEW WAY
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-5285
Mailing Address - Country:US
Mailing Address - Phone:917-575-8045
Mailing Address - Fax:
Practice Address - Street 1:1770 ROCKVIEW WAY
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-5285
Practice Address - Country:US
Practice Address - Phone:917-575-8045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-06
Last Update Date:2020-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
86072483133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty