Basic Information
| Provider Information | |||||||||
| NPI: | 1952304016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | TONY | ||||||||
| MiddleName: | KYUNGSOO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24318 HEMLOCK AVE | ||||||||
| Address2: | E5 | ||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925577222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514851918 | ||||||||
| FaxNumber: | 9513465600 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 MARKET ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHARLESTOWN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471119535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022449859 | ||||||||
| FaxNumber: | 7705739513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 03/28/2016 | ||||||||
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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 | 111N00000X | DC27102 | CA | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 08002884A | 01 | IN | INDIANA LICENSE | OTHER |