Provider Demographics
NPI:1275531261
Name:GRACE HEALTHCARE LABORATORY, INC.
Entity Type:Organization
Organization Name:GRACE HEALTHCARE LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-863-3331
Mailing Address - Street 1:1120 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2414
Mailing Address - Country:US
Mailing Address - Phone:228-863-3331
Mailing Address - Fax:228-863-3392
Practice Address - Street 1:1120 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2414
Practice Address - Country:US
Practice Address - Phone:228-863-3331
Practice Address - Fax:228-863-3392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09752571Medicaid