Provider Demographics
NPI:1649890211
Name:SOUTHERN GRACE MEDICAL CARE, LLC
Entity type:Organization
Organization Name:SOUTHERN GRACE MEDICAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:WINN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP, NP-C
Authorized Official - Phone:256-797-4118
Mailing Address - Street 1:1606 MOONTOWN RD
Mailing Address - Street 2:
Mailing Address - City:BROWNSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35741-9493
Mailing Address - Country:US
Mailing Address - Phone:256-776-3850
Mailing Address - Fax:
Practice Address - Street 1:500 GOVERNORS DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5126
Practice Address - Country:US
Practice Address - Phone:256-797-4118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL23529OtherALABAMA BOARD OF MEDICAL EXAMINERS
AL8499OtherALABAMA BOARD OF NURSING, RX NUMBER
AL1-159682OtherALABAMA BOARD OF NURSING, RN LICENSE NUMBER