=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740037134
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE GRACE MEDICAL ADULT DAYCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2024
-----------------------------------------------------
Last Update Date | 05/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9160 RED BRANCH RD STE E1
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21045-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-745-2110
-----------------------------------------------------
Fax | 443-745-4716
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9160 RED BRANCH RD STE E1
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21045-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-745-2110
-----------------------------------------------------
Fax | 443-745-4716
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | SUNGKI LIM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-785-6055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------