Provider Demographics
NPI:1821645896
Name:GRACE MOUNTAIN MEDICAL, LLC
Entity Type:Organization
Organization Name:GRACE MOUNTAIN MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:SHEPHERD HATFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-226-8677
Mailing Address - Street 1:338 KY RT 550
Mailing Address - Street 2:
Mailing Address - City:EASTERN
Mailing Address - State:KY
Mailing Address - Zip Code:41622
Mailing Address - Country:US
Mailing Address - Phone:606-226-8677
Mailing Address - Fax:
Practice Address - Street 1:338 KY RT 550
Practice Address - Street 2:
Practice Address - City:EASTERN
Practice Address - State:KY
Practice Address - Zip Code:41622
Practice Address - Country:US
Practice Address - Phone:606-226-8677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-23
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty