Healthcare Provider Details

I. General information

NPI: 1497371108
Provider Name (Legal Business Name): GRACE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 ACORN ST STE A
FORT PIERCE FL
34947-4746
US

IV. Provider business mailing address

2504 ACORN STREET STE A
FORT PIERCE FL
34947
US

V. Phone/Fax

Practice location:
  • Phone: 772-837-7800
  • Fax: 772-837-7801
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BARBIE BRUNET
Title or Position: OWNER/PROVIDER
Credential: ARNP
Phone: 772-837-7800