Provider Demographics
NPI:1619840303
Name:KIM, HAE KYUN
Entity type:Individual
Prefix:
First Name:HAE KYUN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BEN
Other - Middle Name:HAE-KYUN
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8201 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1619
Mailing Address - Country:US
Mailing Address - Phone:708-835-7582
Mailing Address - Fax:
Practice Address - Street 1:7500 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:NORRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60706-1196
Practice Address - Country:US
Practice Address - Phone:708-456-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-29
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960057322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer