Provider Demographics
NPI:1700484821
Name:GRACE PHYSICIANS SERVICES
Entity Type:Organization
Organization Name:GRACE PHYSICIANS SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS-METTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-743-6411
Mailing Address - Street 1:1483 OLD CHEROKEE ROAD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072
Mailing Address - Country:US
Mailing Address - Phone:803-766-7686
Mailing Address - Fax:803-399-8038
Practice Address - Street 1:1483 OLD CHEROKEE ROAD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072
Practice Address - Country:US
Practice Address - Phone:803-766-7686
Practice Address - Fax:803-399-8038
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACE CAREGIVERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-12
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC253Z00000XMedicaid