Provider Demographics
NPI:1740475508
Name:GRACE NIKLAS
Entity type:Organization
Organization Name:GRACE NIKLAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIKLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-749-6131
Mailing Address - Street 1:210 WHITING ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-3724
Mailing Address - Country:US
Mailing Address - Phone:781-749-6131
Mailing Address - Fax:
Practice Address - Street 1:210 WHITING ST
Practice Address - Street 2:SUITE 4
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043-3724
Practice Address - Country:US
Practice Address - Phone:781-749-6131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty