Provider Demographics
NPI:1861707986
Name:GRACE FAMILY MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:GRACE FAMILY MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WON
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-638-1347
Mailing Address - Street 1:2100 S EUCLID ST STE 102
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-4572
Mailing Address - Country:US
Mailing Address - Phone:714-638-1347
Mailing Address - Fax:714-534-2098
Practice Address - Street 1:2100 S EUCLID ST STE 102
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-4572
Practice Address - Country:US
Practice Address - Phone:714-638-1347
Practice Address - Fax:714-534-2098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101111208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty