Basic Information
| Provider Information | |||||||||
| NPI: | 1609028539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | KYU YUP | ||||||||
| MiddleName: | |||||||||
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| Credential: | MHP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 707 W WAVELAND AVE | ||||||||
| Address2: | #1001 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606134188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733668939 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1023 BURLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | WESTERN SPRINGS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605581516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083540826 | ||||||||
| FaxNumber: | 7083540867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2008 | ||||||||
| LastUpdateDate: | 10/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.