1023679040 NPI number — LORI S GRACE NP

Table of content: LORI S GRACE NP (NPI 1023679040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023679040 NPI number — LORI S GRACE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRACE
Provider First Name:
LORI
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
LORI
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023679040
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2335 CHURCH ST STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZACHARY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70791-2700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-570-2489
Provider Business Mailing Address Fax Number:
225-570-2986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6550 MAIN ST STE 3500
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZACHARY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70791-4092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-658-6780
Provider Business Practice Location Address Fax Number:
225-658-6781
Provider Enumeration Date:
06/21/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP206404 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2506081 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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