Provider Demographics
NPI:1386274132
Name:KIM, HAERIN
Entity type:Individual
Prefix:
First Name:HAERIN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HAESO-RO 20
Mailing Address - Street 2:BYEOKSAN WOONAM YEON-RI APT 410-1401
Mailing Address - City:PAJU-SI
Mailing Address - State:GYEONGGI-DO
Mailing Address - Zip Code:10893
Mailing Address - Country:KR
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HAESO-RO 20
Practice Address - Street 2:BYEOKSAN WOONAM YEON-RI APT 410-1401
Practice Address - City:PAJU-SI
Practice Address - State:GYEONGGI-DO
Practice Address - Zip Code:10893
Practice Address - Country:KR
Practice Address - Phone:208-997-8228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-21
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPWC-C-10975-AAA-42255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer