Provider Demographics
NPI:1386929834
Name:GRACE TO YOU PEDIATRICS
Entity type:Organization
Organization Name:GRACE TO YOU PEDIATRICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADNIBISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANIEMA
Authorized Official - Middle Name:
Authorized Official - Last Name:UMOH
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:214-239-0980
Mailing Address - Street 1:2665 VILLA CREEK DR STE 201
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2665 VILLA CREEK DR STE 201
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7337
Practice Address - Country:US
Practice Address - Phone:214-239-0980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACE TO YOU HEALTHCARE SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008908251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========Medicaid