Provider Demographics
NPI:1598202293
Name:GRACE LEE PENG, MD
Entity Type:Organization
Organization Name:GRACE LEE PENG, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-533-4493
Mailing Address - Street 1:324 S BEVERLY DR # 150
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-4801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:324 S BEVERLY DR # 150
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-4801
Practice Address - Country:US
Practice Address - Phone:415-533-4493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center