Provider Demographics
NPI:1235318577
Name:GRACE FAMILY MEDICINE
Entity Type:Organization
Organization Name:GRACE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEEHAN-DE LA CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-694-0013
Mailing Address - Street 1:902 FLEMING ST STE B
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28791-3504
Mailing Address - Country:US
Mailing Address - Phone:828-694-0013
Mailing Address - Fax:828-693-3430
Practice Address - Street 1:902 FLEMING ST STE B
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28791-3504
Practice Address - Country:US
Practice Address - Phone:828-694-0013
Practice Address - Fax:828-693-3430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC86400173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH02855Medicare UPIN