Provider Demographics
NPI:1073202115
Name:BY HIS GRACE PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:BY HIS GRACE PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNO, CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:334-806-9233
Mailing Address - Street 1:806 GLOVER AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2018
Mailing Address - Country:US
Mailing Address - Phone:334-475-2680
Mailing Address - Fax:334-475-2681
Practice Address - Street 1:806 GLOVER AVE STE A
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2018
Practice Address - Country:US
Practice Address - Phone:334-475-2680
Practice Address - Fax:334-475-2681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty