Provider Demographics
NPI:1700213790
Name:GRACE COMMUNITY HEALTH CENTER INC
Entity Type:Organization
Organization Name:GRACE COMMUNITY HEALTH CENTER INC
Other - Org Name:PACES CREEK ELEMENTARY SCHOOL BASED CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-526-9005
Mailing Address - Street 1:1019 CUMBERLAND FALLS HWY
Mailing Address - Street 2:SUITE B201
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2735
Mailing Address - Country:US
Mailing Address - Phone:606-526-9005
Mailing Address - Fax:606-526-8606
Practice Address - Street 1:1983 S HIGHWAY 421
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-7514
Practice Address - Country:US
Practice Address - Phone:606-598-6333
Practice Address - Fax:606-552-6860
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACE COMMUNITY HEALTH CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-04
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY700188261QF0400X, 261QP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty