Provider Demographics
NPI:1194848291
Name:FONG, KIM (LACPT)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:FONG
Suffix:
Gender:F
Credentials:LACPT
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:415 RAHWAY AVE
Mailing Address - Street 2:1ST FLOOR, REAR
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-3371
Mailing Address - Country:US
Mailing Address - Phone:908-301-9055
Mailing Address - Fax:908-301-9056
Practice Address - Street 1:415 RAHWAY AVE
Practice Address - Street 2:1ST FLOOR, REAR
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-3371
Practice Address - Country:US
Practice Address - Phone:908-301-9055
Practice Address - Fax:908-301-9056
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00021400171100000X
NJ40QA006801002251P0200X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171100000XOther Service ProvidersAcupuncturist
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ049839Medicare ID - Type Unspecified