Basic Information
| Provider Information | |||||||||
| NPI: | 1497274617 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | IM | ||||||||
| FirstName: | YOUNG | ||||||||
| MiddleName: | VIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8051 MADIA CIR | ||||||||
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| City: | LA PALMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906231926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144022802 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 ADAMS AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926264865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145562288 | ||||||||
| FaxNumber: | 7144351745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 17904 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.