Provider Demographics
NPI:1407293954
Name:GRACE FAMILY MEDICINE CLINIC
Entity Type:Organization
Organization Name:GRACE FAMILY MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:UZOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:OBUEKWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-494-5225
Mailing Address - Street 1:200 HARVEST RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201-5109
Mailing Address - Country:US
Mailing Address - Phone:276-494-5225
Mailing Address - Fax:276-644-4434
Practice Address - Street 1:300 MOORE ST
Practice Address - Street 2:SUITE A
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201-4495
Practice Address - Country:US
Practice Address - Phone:276-644-4433
Practice Address - Fax:276-644-4434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-23
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101244053261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care