Provider Demographics
NPI:1013523166
Name:IM, GRACE SEONG EUN (OMD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:SEONG EUN
Last Name:IM
Suffix:
Gender:F
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5618 ALTA PEAK CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-1905
Mailing Address - Country:US
Mailing Address - Phone:702-245-0160
Mailing Address - Fax:
Practice Address - Street 1:3030 S JONES BLVD STE 107
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6793
Practice Address - Country:US
Practice Address - Phone:702-708-2207
Practice Address - Fax:888-809-4639
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2038171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist