Provider Demographics
NPI:1104567304
Name:GRACIOUS SERVICES LLC
Entity type:Organization
Organization Name:GRACIOUS SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MUDIRA
Authorized Official - Middle Name:T
Authorized Official - Last Name:OYEWOLE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:773-742-8726
Mailing Address - Street 1:1510 SELKIRK ST
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-4317
Mailing Address - Country:US
Mailing Address - Phone:773-742-8726
Mailing Address - Fax:
Practice Address - Street 1:1510 SELKIRK ST
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-4317
Practice Address - Country:US
Practice Address - Phone:773-742-8726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty