1275190043 NPI number — GRIMSLEY'S GRACE, LLC

Table of content: (NPI 1275190043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275190043 NPI number — GRIMSLEY'S GRACE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRIMSLEY'S GRACE, 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:
1275190043
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 826
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVER SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34489-0826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-812-8447
Provider Business Mailing Address Fax Number:
352-694-2060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2331 NE 42ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34479-8908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-812-8447
Provider Business Practice Location Address Fax Number:
352-624-0318
Provider Enumeration Date:
05/28/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GRIMSLEY
Authorized Official First Name:
KAYLA
Authorized Official Middle Name:
N
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
352-812-8447

Provider Taxonomy Codes

  • Taxonomy code: 372600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 376J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 103096900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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