Provider Demographics
NPI:1235639691
Name:PEARL E. GRIMES MD, INC.
Entity Type:Organization
Organization Name:PEARL E. GRIMES MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ESTELA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEGURA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-467-4389
Mailing Address - Street 1:5670 WILSHIRE BLVD STE 650
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-5609
Mailing Address - Country:US
Mailing Address - Phone:323-467-4389
Mailing Address - Fax:323-467-4488
Practice Address - Street 1:5670 WILSHIRE BLVD STE 650
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-5609
Practice Address - Country:US
Practice Address - Phone:323-467-4389
Practice Address - Fax:323-467-4488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51930207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1790702751OtherOTHER