Provider Demographics
NPI:1457656639
Name:GRACE MYOFASCIAL CLINIC, LLC
Entity Type:Organization
Organization Name:GRACE MYOFASCIAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:WEILENMAN
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-717-0910
Mailing Address - Street 1:3000 OLD CANTON RD STE 240
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4235
Mailing Address - Country:US
Mailing Address - Phone:601-717-0910
Mailing Address - Fax:769-257-6382
Practice Address - Street 1:3000 OLD CANTON RD STE 240
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4235
Practice Address - Country:US
Practice Address - Phone:601-717-0910
Practice Address - Fax:769-257-6382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3632261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy