Provider Demographics
NPI:1326885294
Name:GRACE PEDIATRICS PL
Entity type:Organization
Organization Name:GRACE PEDIATRICS PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-243-8474
Mailing Address - Street 1:4196 W US HIGHWAY 90 STE 105
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-8834
Mailing Address - Country:US
Mailing Address - Phone:386-243-8474
Mailing Address - Fax:386-438-5945
Practice Address - Street 1:238 SW CULLEN AVE
Practice Address - Street 2:
Practice Address - City:FORT WHITE
Practice Address - State:FL
Practice Address - Zip Code:32038-3536
Practice Address - Country:US
Practice Address - Phone:386-243-8474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health