1215741269 NPI number — GRACE MOORE JONASSON DC

Table of content: GRACE MOORE JONASSON DC (NPI 1215741269)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215741269 NPI number — GRACE MOORE JONASSON DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JONASSON
Provider First Name:
GRACE
Provider Middle Name:
MOORE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOORE
Provider Other First Name:
GRACE
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215741269
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 BURLER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27292-1285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-906-7754
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
833 JULIAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THOMASVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27360-5848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-476-9600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2025

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: 111N00000X , with the licence number:  5866 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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