Provider Demographics
NPI:1659944783
Name:GRACE WILLIAM HEALTH SYSTEMS
Entity Type:Organization
Organization Name:GRACE WILLIAM HEALTH SYSTEMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OLAOLUWASUPO
Authorized Official - Middle Name:
Authorized Official - Last Name:OJO
Authorized Official - Suffix:
Authorized Official - Credentials:DOL
Authorized Official - Phone:443-865-6503
Mailing Address - Street 1:714 MAIN STREET
Mailing Address - Street 2:SUITE #200
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6074
Mailing Address - Country:US
Mailing Address - Phone:443-865-6503
Mailing Address - Fax:541-887-2291
Practice Address - Street 1:714 MAIN STREET
Practice Address - Street 2:SUITE #200
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6074
Practice Address - Country:US
Practice Address - Phone:541-880-6031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-16
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500805936Medicaid