Provider Demographics
NPI:1588961619
Name:KIM, SUNGRYUL
Entity type:Individual
Prefix:
First Name:SUNGRYUL
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 PLUMOSA DR
Mailing Address - Street 2:
Mailing Address - City:GRIMESLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27837-9187
Mailing Address - Country:US
Mailing Address - Phone:412-728-5868
Mailing Address - Fax:
Practice Address - Street 1:2415 W VERNON AVE
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28504-3337
Practice Address - Country:US
Practice Address - Phone:252-550-1169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-25
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032113225100000X
NC13801225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist