Basic Information
| Provider Information | |||||||||
| NPI: | 1265163802 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIM | ||||||||
| FirstName: | JUNSEOK | ||||||||
| MiddleName: | |||||||||
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| Credential: | AUD | ||||||||
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| OtherLastName: | SHIM | ||||||||
| OtherFirstName: | JOHN | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6700 WASHINGTON AVE S | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443405 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 23822 VALENCIA BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913555303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612533277 | ||||||||
| FaxNumber: | 6612891490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2022 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 231H00000X | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | 3704 | CA | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.