MEDICARE: DR. GRACE G KIM D.P.T.

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	225100000X	Physical Therapist	035726-1	NY

General Provider Information

NPI Number	:	1366787103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRACE G KIM D.P.T.

Provider Business Mailing Address
First Line	:	375 DOVER CHESTER RD
Second Line	:
City	:	RANDOLPH
State	:	NJ
Zip	:	07869-3910
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	375 DOVER CHESTER RD
Second Line	:
City	:	RANDOLPH
State	:	NJ
Zip	:	07869-3910
Country	:	US
Telephone Number	:	973-252-9402
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2012
Last Update Date	:	12/05/2012

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