Provider Demographics
NPI:1679979280
Name:SOVEREIGN GRACE THERAPY
Entity Type:Organization
Organization Name:SOVEREIGN GRACE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:SANJEE BENJAMIN
Authorized Official - Middle Name:GERALDE
Authorized Official - Last Name:ANG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:319-601-9768
Mailing Address - Street 1:1850 SUNNYSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-4423
Mailing Address - Country:US
Mailing Address - Phone:319-601-9768
Mailing Address - Fax:
Practice Address - Street 1:1850 SUNNYSIDE AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-4423
Practice Address - Country:US
Practice Address - Phone:319-601-9768
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-08
Last Update Date:2014-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03690225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty