Basic Information
Provider Information | |||||||||
NPI: | 1699191494 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIM | ||||||||
FirstName: | MINAH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5043 AUBURN WAY S | ||||||||
Address2: |   | ||||||||
City: | AUBURN | ||||||||
State: | WA | ||||||||
PostalCode: | 980927205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3602927245 | ||||||||
FaxNumber: | 3602927246 | ||||||||
Practice Location | |||||||||
Address1: | 5322 ORCHARD ST W | ||||||||
Address2: |   | ||||||||
City: | UNIVERSITY PLACE | ||||||||
State: | WA | ||||||||
PostalCode: | 984673633 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2534763333 | ||||||||
FaxNumber: | 2534763334 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/17/2014 | ||||||||
LastUpdateDate: | 03/17/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA60422590 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |   |
No ID Information.