Provider Demographics
NPI:1710371992
Name:GRACE, MARIA ASTRID KIM JIMENEZ (PTA)
Entity Type:Individual
Prefix:MISS
First Name:MARIA ASTRID KIM
Middle Name:JIMENEZ
Last Name:GRACE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8091 CONSTANTINE DR APT 4
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-1726
Mailing Address - Country:US
Mailing Address - Phone:714-483-4970
Mailing Address - Fax:
Practice Address - Street 1:330 GOLDEN SHR
Practice Address - Street 2:SUITE 250
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-4246
Practice Address - Country:US
Practice Address - Phone:562-256-7550
Practice Address - Fax:800-985-5002
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT9671171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor