Provider Demographics
NPI:1306373188
Name:GRACEOL CORPORATION
Entity Type:Organization
Organization Name:GRACEOL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:YEMI
Authorized Official - Middle Name:J
Authorized Official - Last Name:SOWEMIMO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:404-839-2688
Mailing Address - Street 1:1035 HONEY CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013
Mailing Address - Country:US
Mailing Address - Phone:404-839-2688
Mailing Address - Fax:770-922-9498
Practice Address - Street 1:1035 HONEY CREEK RD
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013
Practice Address - Country:US
Practice Address - Phone:404-839-2688
Practice Address - Fax:770-922-9498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1639177066OtherNPI
NY1912016411OtherNPI
GA1790107381OtherNPI