Provider Demographics
NPI:1164567772
Name:KIM, GRACE JUNG
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:JUNG
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4834 SMOKE TREE RD
Mailing Address - Street 2:
Mailing Address - City:PHELAN
Mailing Address - State:CA
Mailing Address - Zip Code:92371-6883
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3777 PHELAN RD
Practice Address - Street 2:
Practice Address - City:PHELAN
Practice Address - State:CA
Practice Address - Zip Code:92371-9074
Practice Address - Country:US
Practice Address - Phone:760-868-5618
Practice Address - Fax:760-868-6688
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9027171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist