Provider Demographics
NPI:1083124671
Name:GRACE FAMILY PRACTICE CLINIC, P.C.
Entity Type:Organization
Organization Name:GRACE FAMILY PRACTICE CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASEY-BOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-288-0911
Mailing Address - Street 1:1716 PARR AVE STE D
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2074
Mailing Address - Country:US
Mailing Address - Phone:731-288-0911
Mailing Address - Fax:731-288-0065
Practice Address - Street 1:1716 PARR AVE STE D
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2074
Practice Address - Country:US
Practice Address - Phone:731-288-0911
Practice Address - Fax:731-288-0065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD35727207Q00000X
TNMD25289207Q00000X
TNAPN13637363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty