MEDICARE: GRACE MEDICAL SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1104577287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE MEDICAL SERVICES LLC

Provider Business Mailing Address
First Line	:	7836 DELAROCHE CT
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-2508
Country	:	US
Telephone Number	:	904-514-3405
Fax Number	:

Provider Business Practice Location Address
First Line	:	7836 DELAROCHE CT
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-2508
Country	:	US
Telephone Number	:	904-514-3405
Fax Number	:

Authorized Official
Title or Position	:	OWNER/LAB DIRECTOR
Name	:	NYEMA EADES
Credential	:	PHD
Telephone Number	:	904-933-7511

Provider Enumeration Date	:	01/11/2022
Last Update Date	:	06/08/2022

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