Provider Demographics
NPI:1043609134
Name:SOUTHERN GRACE HEALTHCARE
Entity Type:Organization
Organization Name:SOUTHERN GRACE HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AUBREY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEKIWI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-432-8811
Mailing Address - Street 1:364 RACETRACK RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-1022
Mailing Address - Country:US
Mailing Address - Phone:678-432-8811
Mailing Address - Fax:678-432-8821
Practice Address - Street 1:364 RACETRACK RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-1022
Practice Address - Country:US
Practice Address - Phone:678-432-8811
Practice Address - Fax:678-432-8821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64068207R00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty