Provider Demographics
NPI:1073898631
Name:HIS GRACE MEDICAL, LLC
Entity Type:Organization
Organization Name:HIS GRACE MEDICAL, LLC
Other - Org Name:LABS AT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EBENEZER
Authorized Official - Middle Name:
Authorized Official - Last Name:ALABI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-704-8081
Mailing Address - Street 1:PO BOX 153202
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-9202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1635 W DIVISION ST
Practice Address - Street 2:SUITE A
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-3810
Practice Address - Country:US
Practice Address - Phone:817-704-8081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-14
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D1091543291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL1124Medicare Oscar/Certification