Provider Demographics
NPI:1376172494
Name:GRACE MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:GRACE MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEADOWS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:304-916-1881
Mailing Address - Street 1:1824 MURDOCH AVE BLDG C
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-3230
Mailing Address - Country:US
Mailing Address - Phone:304-916-1881
Mailing Address - Fax:
Practice Address - Street 1:1824 MURDOCH AVE BLDG C
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-3230
Practice Address - Country:US
Practice Address - Phone:304-916-1881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-02
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty