Provider Demographics
NPI:1609978824
Name:GRACE MEDICAL CLINICS P.A.
Entity Type:Organization
Organization Name:GRACE MEDICAL CLINICS P.A.
Other - Org Name:GRACE MEDICAL CLINICS P.A
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLUFEMI
Authorized Official - Middle Name:A
Authorized Official - Last Name:TOKUNBOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-933-2101
Mailing Address - Street 1:2317 CONCORD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2813
Mailing Address - Country:US
Mailing Address - Phone:704-933-2101
Mailing Address - Fax:704-933-1150
Practice Address - Street 1:2317 CONCORD LAKE RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2813
Practice Address - Country:US
Practice Address - Phone:704-933-2101
Practice Address - Fax:704-933-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89011GGMedicaid
NC89011GGMedicaid
NC2255330DMedicare ID - Type Unspecified