Basic Information
Provider Information
NPI: 1730443060
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: YOON
FirstName: GRACE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: OD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
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OtherCredential:  
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Mailing Information
Address1: 14405 W COLFAX AVE
Address2: #310
City: LAKEWOOD
State: CO
PostalCode: 804013247
CountryCode: US
TelephoneNumber: 3032150376
FaxNumber: 3033026906
Practice Location
Address1: 4550 E CACTUS RD
Address2: #30
City: PHOENIX
State: AZ
PostalCode: 850327711
CountryCode: US
TelephoneNumber: 6024851300
FaxNumber: 6024941029
Other Information
ProviderEnumerationDate: 07/02/2012
LastUpdateDate: 07/02/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
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AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X1856AZY Eye and Vision Services ProvidersOptometrist 

No ID Information.


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