Provider Demographics
NPI:1023626033
Name:KIM, SERIN (DPT)
Entity type:Individual
Prefix:
First Name:SERIN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 E PROHASKA ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6673
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77 N FISHER PARK WAY
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4796
Practice Address - Country:US
Practice Address - Phone:208-297-3039
Practice Address - Fax:208-416-6635
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6734225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist