Provider Demographics
NPI:1346420668
Name:HIS GRACE MEDICAL LLC
Entity Type:Organization
Organization Name:HIS GRACE MEDICAL LLC
Other - Org Name:6055 CLEVELAND AVENUE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:RN/OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FEYISAYO
Authorized Official - Middle Name:OLUWATOSIN
Authorized Official - Last Name:TOLANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-315-1836
Mailing Address - Street 1:6055 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-2256
Mailing Address - Country:US
Mailing Address - Phone:614-315-1836
Mailing Address - Fax:888-491-4030
Practice Address - Street 1:6055 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-2256
Practice Address - Country:US
Practice Address - Phone:614-315-1836
Practice Address - Fax:888-491-4030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084618261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2509020Medicaid