Provider Demographics
NPI:1164900627
Name:GRACE, RODDY DANIEL (N/A)
Entity Type:Individual
Prefix:
First Name:RODDY
Middle Name:DANIEL
Last Name:GRACE
Suffix:
Gender:M
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 810
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-0810
Mailing Address - Country:US
Mailing Address - Phone:541-813-2535
Mailing Address - Fax:
Practice Address - Street 1:615 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9199
Practice Address - Country:US
Practice Address - Phone:541-813-2535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator