1710371992 NPI number — MISS MARIA ASTRID KIM JIMENEZ GRACE PTA

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 1710371992 NPI number — MISS MARIA ASTRID KIM JIMENEZ GRACE PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRACE
Provider First Name:
MARIA ASTRID KIM
Provider Middle Name:
JIMENEZ
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1710371992
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8091 CONSTANTINE DR APT 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92646-1726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-483-4970
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 GOLDEN SHR
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90802-4246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-256-7550
Provider Business Practice Location Address Fax Number:
800-985-5002
Provider Enumeration Date:
03/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X , with the licence number:  AT9671 , 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)





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