MEDICARE: PEARL E. GRIMES MD, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	G51930	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1790702751	OTHER	CA	OTHER

General Provider Information

NPI Number	:	1235639691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEARL E. GRIMES MD, INC.

Provider Business Mailing Address
First Line	:	5670 WILSHIRE BLVD STE 650
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-5609
Country	:	US
Telephone Number	:	323-467-4389
Fax Number	:	323-467-4488

Provider Business Practice Location Address
First Line	:	5670 WILSHIRE BLVD STE 650
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-5609
Country	:	US
Telephone Number	:	323-467-4389
Fax Number	:	323-467-4488

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	ESTELA SEGURA
Credential	:
Telephone Number	:	323-467-4389

Provider Enumeration Date	:	02/12/2018
Last Update Date	:	02/12/2018

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