1588857304 NPI number — GRACE IVIE EJAIFE-AUSTIN DPM

Table of content: GRACE IVIE EJAIFE-AUSTIN DPM (NPI 1588857304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588857304 NPI number — GRACE IVIE EJAIFE-AUSTIN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EJAIFE-AUSTIN
Provider First Name:
GRACE
Provider Middle Name:
IVIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

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:
1588857304
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13007 BROWN BRIDGE RD, SUITE # 300
Provider Second Line Business Mailing Address:
PMB 117#
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-360-7939
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
803 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30642-1211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-360-7939
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2007

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: 213E00000X , with the licence number:  POD001084 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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