Provider Demographics
NPI:1053594846
Name:SOO YOUN KIM OD INC
Entity type:Organization
Organization Name:SOO YOUN KIM OD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOO
Authorized Official - Middle Name:YOUN
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-628-0300
Mailing Address - Street 1:14147 PIPELINE AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-5618
Mailing Address - Country:US
Mailing Address - Phone:909-628-0300
Mailing Address - Fax:
Practice Address - Street 1:14147 PIPELINE AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-5618
Practice Address - Country:US
Practice Address - Phone:909-628-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ZZZ25706Z
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-14
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT10349TPA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0125235Medicaid
CAZZZ25706ZMedicare PIN