Provider Demographics
NPI:1407186877
Name:GRACE MEDICAL PRACTICE LLC
Entity Type:Organization
Organization Name:GRACE MEDICAL PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:FIDELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:OSINUBI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-861-0291
Mailing Address - Street 1:PO BOX 20156
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30325-0156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3885 PRINCETON LAKES WAY SW
Practice Address - Street 2:SUITE 402
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5589
Practice Address - Country:US
Practice Address - Phone:404-349-0496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-07
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA061309261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care