Basic Information
| Provider Information | |||||||||
| NPI: | 1710555206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YANG | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | DA EUN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3215 W PICO BLVD APT 414 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900193657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107753146 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4510 E PACIFIC COAST HWY STE 600 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908046914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5623461100 | ||||||||
| FaxNumber: | 5629617604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2021 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.