Provider Demographics
NPI:1114996840
Name:GRACE OPTICAL
Entity Type:Organization
Organization Name:GRACE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIYOUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:YOON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:718-231-9000
Mailing Address - Street 1:3409 JEROME AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-1049
Mailing Address - Country:US
Mailing Address - Phone:718-231-9000
Mailing Address - Fax:
Practice Address - Street 1:3409 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-1049
Practice Address - Country:US
Practice Address - Phone:718-231-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006830152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00327000Medicaid
NYC87441Medicare PIN
NYC19761Medicare PIN
NY00327000Medicaid
NY0237420001Medicare NSC