Provider Demographics
NPI:1831544576
Name:KIM, SU
Entity type:Individual
Prefix:
First Name:SU
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 1:522 S VERDUGO DR
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-2344
Mailing Address - Country:US
Mailing Address - Phone:818-562-9605
Mailing Address - Fax:
Practice Address - Street 1:522 S VERDUGO DR
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502
Practice Address - Country:US
Practice Address - Phone:818-562-9605
Practice Address - Fax:818-562-9606
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261212965332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies