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General NPI Number Information
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NPI Number | 1932562360
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Entity Type | Organization
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Legal Business Name | GRAY PEARLS LLC
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Dates
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Enumeration Date | 04/02/2016
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Last Update Date | 04/02/2016
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Provider Practice Location Address
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Address Line | 2506 TRAMWAY TERRACE CT NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87122-2317
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Country | US
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Telephone | 505-506-1984
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Fax |
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Provider Business Mailing Address
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Address Line | 2506 TRAMWAY TERRACE CT NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87122-2317
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Country | US
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Telephone | 505-506-1984
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER/PHYSICIAN
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Name | ELLEN KIM
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Credential | M.D.
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Telephone | 505-506-1984
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | 97-289
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License Number State | NM
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