Provider Demographics
NPI:1063082469
Name:GRACE, LEVI DAKOTA
Entity type:Individual
Prefix:MR
First Name:LEVI
Middle Name:DAKOTA
Last Name:GRACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 CHAD GRACE RD
Mailing Address - Street 2:
Mailing Address - City:RED BOILING SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37150-7309
Mailing Address - Country:US
Mailing Address - Phone:931-310-0107
Mailing Address - Fax:
Practice Address - Street 1:615 MCCALLIE AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2504
Practice Address - Country:US
Practice Address - Phone:423-425-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer