Provider Demographics
NPI:1982211223
Name:GRACE, SEAN DAVVID
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:DAVVID
Last Name:GRACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3236
Mailing Address - Country:US
Mailing Address - Phone:405-584-2350
Mailing Address - Fax:
Practice Address - Street 1:14430 NS 3500
Practice Address - Street 2:
Practice Address - City:KONAWA
Practice Address - State:OK
Practice Address - Zip Code:74849-4901
Practice Address - Country:US
Practice Address - Phone:580-925-2650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKJ083106885Medicaid