Provider Demographics
NPI:1104107192
Name:GRACE PLACE FOR WOMEN, INCORPORATED
Entity type:Organization
Organization Name:GRACE PLACE FOR WOMEN, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-327-4747
Mailing Address - Street 1:PO BOX 2256
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-2256
Mailing Address - Country:US
Mailing Address - Phone:505-327-4747
Mailing Address - Fax:505-327-2025
Practice Address - Street 1:4801 N BUTLER AVE STE 3102
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-0815
Practice Address - Country:US
Practice Address - Phone:505-327-4747
Practice Address - Fax:505-327-2025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-02
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2010-0578207V00000X
NMPA2008-0053363A00000X
NMMD2010-0229207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty