Provider Demographics
NPI:1518548262
Name:GRACELAND PSYCHIATRIC AND NEUROMODULATION CENTER PLLC
Entity type:Organization
Organization Name:GRACELAND PSYCHIATRIC AND NEUROMODULATION CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:POPOOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-868-5801
Mailing Address - Street 1:2411 NE LOOP 410 STE 114
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-6600
Mailing Address - Country:US
Mailing Address - Phone:210-868-5801
Mailing Address - Fax:726-201-1558
Practice Address - Street 1:2411 NE LOOP 410 STE 114
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-6600
Practice Address - Country:US
Practice Address - Phone:210-868-5801
Practice Address - Fax:726-201-1558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-15
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty