1154083376 NPI number — GRACE GYNECOLOGY & WELLNESS CORP APMC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154083376 NPI number — GRACE GYNECOLOGY & WELLNESS CORP APMC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE GYNECOLOGY & WELLNESS CORP APMC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154083376
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 BEAULLIEU DR STE 3B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-7230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-522-7282
Provider Business Mailing Address Fax Number:
337-393-7057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 BEAULLIEU DR STE 3B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70508-7230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-522-7282
Provider Business Practice Location Address Fax Number:
337-393-7057
Provider Enumeration Date:
10/06/2021

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
MIKA
Authorized Official Middle Name:
MARLAINE
Authorized Official Title or Position:
PHYSICIAN/PRESIDENT OF CORP
Authorized Official Telephone Number:
337-654-4729

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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