Provider Demographics
NPI:1154954196
Name:GRACE FAMILY HEALTH LLC
Entity type:Organization
Organization Name:GRACE FAMILY HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-C
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-645-2218
Mailing Address - Street 1:2110 S JOHN REDDITT DR STE D
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-5488
Mailing Address - Country:US
Mailing Address - Phone:936-209-4660
Mailing Address - Fax:936-209-4660
Practice Address - Street 1:303 E DENMAN AVE STE A
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-4090
Practice Address - Country:US
Practice Address - Phone:936-209-4660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP144710OtherLICENSE NUMBER