Provider Demographics
NPI:1124552864
Name:SUPERIOR GRACE ENTERPRISE LLC
Entity Type:Organization
Organization Name:SUPERIOR GRACE ENTERPRISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LSA
Authorized Official - Phone:214-886-9766
Mailing Address - Street 1:2005 BISHOP DR
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-4058
Mailing Address - Country:US
Mailing Address - Phone:214-886-9766
Mailing Address - Fax:
Practice Address - Street 1:2005 BISHOP DR
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-4058
Practice Address - Country:US
Practice Address - Phone:214-886-9766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00597363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty