Provider Demographics
NPI:1457674269
Name:GRACE FAMILY CARE, PC
Entity Type:Organization
Organization Name:GRACE FAMILY CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:C
Authorized Official - Last Name:PAMINTUAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-921-6659
Mailing Address - Street 1:10616 METROMONT PKWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-7656
Mailing Address - Country:US
Mailing Address - Phone:704-921-6659
Mailing Address - Fax:704-921-6698
Practice Address - Street 1:10616 METROMONT PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-7657
Practice Address - Country:US
Practice Address - Phone:704-921-6659
Practice Address - Fax:704-921-6698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCN 97 00121261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891070PMedicaid
NCG45579Medicare UPIN
NC2236483CMedicare PIN