Provider Demographics
NPI:1295290963
Name:GRACE HEALTH CLINIC
Entity type:Organization
Organization Name:GRACE HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BIANCA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-259-4854
Mailing Address - Street 1:1415 CORPORATE SQUARE DR STE A
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3151
Mailing Address - Country:US
Mailing Address - Phone:985-259-4854
Mailing Address - Fax:855-807-4750
Practice Address - Street 1:1415 CORPORATE SQUARE DR STE A
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-3151
Practice Address - Country:US
Practice Address - Phone:985-259-4854
Practice Address - Fax:855-807-4750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05427361Medicaid
LA2427806Medicaid