1568730885 NPI number — GRACE LIU MD INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568730885 NPI number — GRACE LIU MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE LIU MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568730885
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3991 MACARTHUR BLVD
Provider Second Line Business Mailing Address:
STE 228
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92660-3009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-863-0988
Provider Business Mailing Address Fax Number:
949-863-0088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 N. MAIN STREET
Provider Second Line Business Practice Location Address:
STE 115
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-6638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-571-0228
Provider Business Practice Location Address Fax Number:
714-571-0167
Provider Enumeration Date:
12/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LIU
Authorized Official First Name:
GRACE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
714-571-0228

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  A61446 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A61446 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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