=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467971283
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRACE Y KIM MA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2017
-----------------------------------------------------
Last Update Date | 09/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | LACDMH HUCLA 1000 W. CARSON STREET
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-222-3198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1596 AVENIDA SELVA
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92833-1553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-445-1479
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------