Provider Demographics
NPI:1285792366
Name:GRACE CHIROPRACTIC CENTER, INC.
Entity type:Organization
Organization Name:GRACE CHIROPRACTIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CLAY
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:501-941-3008
Mailing Address - Street 1:PO BOX 688
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-0688
Mailing Address - Country:US
Mailing Address - Phone:501-941-3008
Mailing Address - Fax:501-941-3007
Practice Address - Street 1:309 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-2911
Practice Address - Country:US
Practice Address - Phone:501-941-3008
Practice Address - Fax:501-941-3007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1674111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y850OtherBLUE CROSS BLUE SHEILD
AR5032683OtherCIGNA
AR7172792OtherAETNA
AR06060023300OtherQUAL CHOICE
ARV09364Medicare UPIN
AR06060023300OtherQUAL CHOICE