Provider Demographics
NPI:1689725103
Name:GRACE PHYSICAL THERAPY P.C.
Entity Type:Organization
Organization Name:GRACE PHYSICAL THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MINSUK
Authorized Official - Middle Name:KWAK
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-321-2511
Mailing Address - Street 1:14250 ROOSEVELT AVE STE 1B
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-6042
Mailing Address - Country:US
Mailing Address - Phone:718-321-2511
Mailing Address - Fax:888-327-6892
Practice Address - Street 1:14250 ROOSEVELT AVE STE 1B
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-6042
Practice Address - Country:US
Practice Address - Phone:718-321-2511
Practice Address - Fax:888-327-6892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015390302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization