Healthcare Provider Details

I. General information

NPI: 1982203519
Provider Name (Legal Business Name): GRACE YOUNG KO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2020
Last Update Date: 10/24/2020
Certification Date: 10/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15009 NORTHERN BLVD FL 4
FLUSHING NY
11354-3888
US

IV. Provider business mailing address

15009 NORTHERN BLVD FL 4
FLUSHING NY
11354-3888
US

V. Phone/Fax

Practice location:
  • Phone: 646-272-8492
  • Fax:
Mailing address:
  • Phone: 646-272-8492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: