Healthcare Provider Details

I. General information

NPI: 1104691468
Provider Name (Legal Business Name): SLIMMING GRACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2023
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 JOHNSON AVE UNIT 3371
KINGMAN AZ
86402-1616
US

IV. Provider business mailing address

PO BOX 3371
KINGMAN AZ
86402-3371
US

V. Phone/Fax

Practice location:
  • Phone: 928-279-5076
  • Fax: 949-695-3692
Mailing address:
  • Phone: 928-279-5076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DANNI OWENS
Title or Position: OWNER
Credential: FNP
Phone: 928-279-5076