Provider Demographics
NPI:1174669568
Name:GRACE HEALTHCARE SERVICES, LLC
Entity Type:Organization
Organization Name:GRACE HEALTHCARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENE
Authorized Official - Middle Name:L
Authorized Official - Last Name:TROTTER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:618-643-3051
Mailing Address - Street 1:104 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MC LEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859-1317
Mailing Address - Country:US
Mailing Address - Phone:618-643-3051
Mailing Address - Fax:618-643-3164
Practice Address - Street 1:104 E MARKET ST
Practice Address - Street 2:
Practice Address - City:MC LEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859-1317
Practice Address - Country:US
Practice Address - Phone:618-643-3051
Practice Address - Fax:618-643-3164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL318602171001Medicaid
IL788058OtherHEALTHLINK #
ILDG2570OtherRAILROAD MEDICARE#
ILP00425296OtherRAILROAD MEDICARE #
IL03332007OtherBCBS #
IL1568446805OtherPERSONAL NPI
ILQ24440OtherUPIN #
ILP00425296OtherRAILROAD MEDICARE #
ILP00425296OtherRAILROAD MEDICARE #
IL=========OtherEIN