1174669568 NPI number — GRACE HEALTHCARE SERVICES, LLC

Table of content: (NPI 1174669568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174669568 NPI number — GRACE HEALTHCARE SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE HEALTHCARE SERVICES, LLC
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:
1174669568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 E MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MC LEANSBORO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62859-1317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-643-3051
Provider Business Mailing Address Fax Number:
618-643-3164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 E MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MC LEANSBORO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62859-1317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-643-3051
Provider Business Practice Location Address Fax Number:
618-643-3164
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TROTTER
Authorized Official First Name:
RENE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICER
Authorized Official Telephone Number:
618-643-3051

Provider Taxonomy Codes

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

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

  • Identifier: 318602171001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 788058 . This is a "HEALTHLINK #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: DG2570 . This is a "RAILROAD MEDICARE#" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00425296 . This is a "RAILROAD MEDICARE #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 03332007 . This is a "BCBS #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1568446805 . This is a "PERSONAL NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: Q24440 . This is a "UPIN #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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